A 62-year-old man presented with anemia (hemoglobin level of 6.9 g/dL). He had a 3-month history of intermittent painless melena. However, the underlying cause of the bleeding had not been identified despite extensive investigations, including upper gastrointestinal (GI) endoscopy, colonoscopy, and small bowel capsule endoscopy. Abdominal contrast-enhanced computed tomography (CT) showed a nonenhancing cystic lesion located at the pancreatic body measuring 10 mm in diameter. The cystic lesion was adjacent to the splenic artery and accompanied by upstream dilatation of the main pancreatic duct. Endoscopic retrograde pancreatography (ERP) demonstrated a communication between the pancreatic duct and the cystic lesion. During ERP, massive pulsatile bleeding was observed via the papilla of Vater, which was consistent with a diagnosis of hemosuccus pancreaticus (Figure). An emergent transcatheter arterial embolization of the splenic artery was successfully performed. The patient was discharged without complications and has had no further episodes of bleeding.
Hemosuccus pancreaticus, defined as bleeding from the papilla of Vater via the pancreatic duct, is a rare and challenging cause of acute and intermittent upper GI bleeding. It is often difficult to diagnose by esophagogastroduodenoscopy (EGD) because of its anatomical location and the intermittent nature of bleeding. Although almost all patients with hemosuccus pancreaticus have an arterial abnormality, the fistula between the pancreatic duct and aneurysm of the peripancreatic vessels are seldom found with angiography. In patients without an aneurysm, as with this case, the diagnosis of hemosuccus pancreaticus will be extremely difficult unless bleeding from the papilla of Vater is observed. This case imparts an important message to look beyond the GI tract when treating a patient with recurrent GI bleeding of undetermined etiology.
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-Sho Kitagawa, MD
