S4668 Spontaneous Hemosuccus Pancreaticus: A Rare Cause of Bleeding From the Ampulla of Vater

Introduction: Hemosuccus pancreaticus is an extremely rare cause of upper gastrointestinal bleed characterized by bleeding from the ampulla of Vater through the pancreatic duct, which can be a result of pancreatic disease itself or related to the surrounding vasculature. Due to its infrequent, intermittent and difficult to visualize nature, it is often missed, even with esophagogastroduodenoscopy (EGD). In severe cases, it can also lead to hypovolemic shock. The few cases reported in literature attribute it to a history of trauma, instrumental manipulation, pseudoaneurysm rupture, infection, autoimmune disease, chronic pancreatitis, or malignancy. We describe a case of a man with chronic abdominal pain, found to have spontaneous bleeding from the ampulla of Vater on EGD. Case Description/Methods: A 68-year-old man with a history of chronic pancreatitis, portal vein thrombosis, and gastroesophageal reflux disease presented with 2 months of abdominal pain, early satiety, nausea, food aversion, and constipation. Outpatient computed tomography abdomen showed pancreatic head fullness, and evaluation with endoscopic ultrasound (EUS) was planned. During EGD, spontaneous bleeding was noted from the duodenal papilla/ampulla of Vater. Endoscopic Ultrasound (EUS) showed fullness in the pancreatic head and body. Biopsies were obtained, which were inconclusive. Triple-phase computed tomography obtained after the procedure did not show active bleeding but again showed pancreatic and mesenteric fullness (1.7 × 3 × 2.5 cm) with mild pancreatic ductal prominence (3 mm) and signs of duodenal obstruction from extrinsic compression. The patient was transferred to another hospital, where repeat EGD showed partial duodenal obstruction. EUS-guided biopsies of the pancreatic head mass this time showed moderate to poorly differentiated adenocarcinoma. An AXIOS™ stent was deployed between the stomach and jejunum to bypass the obstruction. Hematology/oncology was consulted with a plan to start neoadjuvant chemotherapy. Discussion: Hemosuccus pancreaticus is a rare condition and its awareness is lacking, leading it to often being missed. It can be an early sign of severe underlying pathology, such as malignancy, and can lead to intractable GI bleed. A high index of suspicion to make an early diagnosis and prompt intervention is key to improving patient outcomes.