This man was brought to hospital via ambulance following a collapse at home, on a background of end-stage kidney disease secondary to hypertension, on haemodialysis, and an episode of gallstone pancreatitis 3 months ago, complicated by complex pancreatic pseudocysts.

In the emergency department, he was found to be hypotensive, with a hemoglobin of 50 g/L, tender epigastrium and copious melena, on digital rectal examination. He underwent red cell transfusion and an upper gastrointestinal endoscopy the next day that found no evidence of active bleeding. His hemoglobin remained stable for several days, and a colonoscope found no source of bleeding either. He proceeded to capsule endoscopy, which revealed fresh blood in the first part of the duodenum, and a mucosal lesion suspicious for malignancy, which was thought to be the source of the bleeding. A repeat endoscopy and biospy subsequently proved the lesion to be benign.

Several days into the admission, the patient passed more melena and his hemoglobin dropped precipitously from 90 g/L to 60 g/L. A multiphase CT angiogram of the abdomen including a delayed venous phase was performed. A small pseudoaneurysm was seen on the arterial phase within one of the pancreatic pseudocysts and appeared to be communicating with the pancreatic duct. As the patient stabilized there was no indication for repeat upper gastrointestinal endoscopy to confirm the diagnosis of hemosuccus pancreaticus.

Thanks to Dr Craig Hacking, Dr Sonja Gustafson, Dr Greg Wilson and Dr James Rowland.