S4841 A Rare Case of Hemosuccus Pancreaticus Caused by Pancreatic Pseudoaneurysm

Introduction: Hemosuccus pancreaticus causes 1/1,500 gastrointestinal (GI) bleeding cases and has a male predilection. It involves bleeding from the Ampulla of Vater into the duodenum. There are multiple potential causes of this condition, though the most common cause involves rupture of a splenic artery aneurysm associated with acute or chronic pancreatitis. The resultant inflammation from pancreatitis leads to vascular wall weakening leading to rupture. Pseudoaneurysm of hepatic, gastroduodenal, and hepatoduodenal arteries have also been implicated in literature. Since the bleeding can be intermittent, it is very challenging to confirm it endoscopically. Case Description/Methods: A 63-year-old man presented from surgery clinic with a 2-week history of epigastric pain, vomiting, and rectal bleeding. Labs on admission were notable for hemoglobin 6.1 g/dl and lipase 3129 U/l. Computed tomography of abdomen/pelvis revealed acute interstitial edematous pancreatitis. Of note, the patient had a history of alcohol abuse, portal vein thrombosis, and necrotizing pancreatitis due to mass effect caused by pseudoaneurysm with high flow arterio-portal fistula formation supplied from a pancreaticoduodenal arterial arcade located at the pancreatic head for which he had history of cystgastrostomy. He had history of coil embolization followed by surgical ligation of the feeding vessels. esophagogastroduodenoscopy performed during admission revealed fresh blood at the Ampulla of Vater suggestive of hemosuccus pancreaticus. Bleeding subsequently stopped. By the time, arteriogram was performed 5 days later, it was normal. When patient presented with bleeding again 2 months later, new hemorrhage was noted within the partially thrombosed pseudoaneurysm sac arising within the distribution of the head of the pancreas for which he underwent gastroduodenal artery pseudoaneurysm embolization. Discussion: Hemosuccus pancreaticus is a rare cause of upper GI bleeding that should be considered in patients with pancreatitis. Early imaging and endoscopic evaluation is imperative to ensure timely intervention. Awareness of this condition, along with timely multidisciplinary collaboration, are essential components in both an accurate diagnosis and favorable outcome.