Hemosuccus pancreaticus

Hemosuccus pancreaticus, also known as pseudohaemobilia or hemoductal pancreatitis, is defined as upper gastrointestinal tract haemorrhage originating from the pancreatic duct into the duodenum via the ampulla of Vater, or major pancreatic papilla.

Epidemiology

• male:female ratio is 7:1
• highly correlated with chronic alcohol abuse
• mean age of onset: 50-60 years ¹
• only ~100 reported cases in the literature between 1967 and 2011

Clinical presentation

A triad of epigastric pain, intermittent gastrointestinal bleeding and hyperamylasaemia ^1,2.

Pathology

The most common aetiology is pseudoaneurysm rupture of the splenic (60-65%)¹, gastroduodenal, or duodenopancreatic artery. Pseudoaneurysm formation is most commonly secondary to chronic pancreatitis and occurs in 10% of this population.

Chronic local inflammation is thought to lead to increased local release of elastase, with either autodigestion of peripancreatic vessels or erosion of a concomitant pseudocyst into the artery³.

Aetiology

From most common to least common:

• pancreatitis
• peripancreatic tumour haemorrhage
• primary vascular aneurysm
• iatrogenic: complication of biopsy/FNA, pancreatic duct stenting, or ERCP
• congenital abnormality
• trauma
• infection: chronic pancreatitis, brucellosis, syphilis

Imaging

Ultrasonography

Ultrasonography can help visualise peripancreatic artery pseudoaneurysms and pancreatic pseudocysts. Real-time Doppler interrogation is a sensitive method for demonstrating intermittent haemorrhage. ⁸

CT

CT angiography (CTA) may show the culprit pseudoaneurysm or pseudocyst, possibly demonstrating active bleeding, along with hyperdense material (i.e. fresh blood, clots) in the pancreatic ducts. In addition, it can visualise other relevant pathology, which can help narrow down the differential diagnosis ⁹.

ERCP

If employed at the time of active bleeding, ERCP can afford direct visualisation of blood seeping through the papilla by means of using a side-viewing endoscope (duodenoscope).

Angiography

As haemorrhage is often intermittent, direct selective angiography is superior in identifying small arterial filling defects and for the identification of small pseudoaneurysms or fistulae ^5,6,8.

Angiography is also used therapeutically (see below).

Nuclear medicine

Radionuclide 99mTc red blood cell scintigraphy is of low diagnostic yield ¹.

Treatment and prognosis

• angiography, with or without coil embolization ^4,6
• surgical debridement and ligation ³: in severe cases, with or without pancreaticoduodenectomy ⁵
• 90% mortality rate in patients treated with supportive therapy only ⁵

History and etymology

First reported in 1931, and later described by P Sandholm in 1970, who reported three patients with gastrointestinal bleeding from pancreatic duct pseudoaneurysm rupture, and coined the term. ⁷