S4706 Hemosuccus Pancreaticus: An Unusual Source of GI Bleeding

Introduction: Hemosuccus pancreaticus (HP) is a hemorrhage from the ampulla of Vater passing through the main pancreatic duct toward the duodenum. Presenting signs and symptoms include epigastric pain that radiates to the back, melena, and hematochezia. Severe cases may present with hematemesis and shock. The abdominal pain may be undulating with fluctuating rates of bleeding, secondary to the movement of the pancreatic ducts. This diagnosis is associated with alcohol use and chronic pancreatitis. HP is a challenging diagnosis to make given its rarity, anatomic location, and ability to mimic other diagnoses such as peptic ulcer disease or gastritis. It carries a mortality risk of 9.6% but with supportive care only, this number approaches 90%. Case Description/Methods: A 69-year-old man with a history of alcoholic cirrhosis and esophageal varices presented with 4 days of melena, severe, undulating epigastric pain, and hypotension. Shortly after admission, he also began to have hematemesis. Lab work was notable for a Hgb of 4.4, a lipase of 402, and a lactic acid of 2.6. He promptly underwent esophagogastroduodenoscopy with push enteroscopy that showed blood in the second portion of the duodenum and brisk bleeding from the ampulla of Vater. Interventional radiology was consulted to perform an angiogram and found a large pseudoaneurysm arising from a branch of the superior pancreaticoduodenal artery. The pseudoaneurysm was embolized with control of the bleeding and resolution of abdominal pain. Discussion: It is estimated that 1 in 1,500 cases of gastrointestinal bleeding are secondary HP. Causes include chronic pancreatitis, arterial aneurysms, pancreatic tumors or pseudocysts, and iatrogenic insults. This case shows several unique aspects in the diagnosis of HP. Firstly, patients do not commonly present with hematemesis, and when they do, it is important to promptly stabilize them. Also, we were fortunate to see active bleeding from the Ampulla of Vater with a forward-facing endoscope, which is seen in only in 30% of cases. Both components guided the rapid diagnosis and treatment of a life-threatening bleed. Other considerations in the diagnosis of HP include the use of ultrasound, which can help identify abdominal aneurysms or pancreatic pseudocysts in a time or resource-limited setting. Angiography remains the optimal approach as it provides both diagnostic and therapeutic modalities. While interventional radiology embolization is the most common intervention and is often successful, there remains a 30% chance of re-bleeding after treatment.