Haemosuccus Pancreaticus

Haemosuccus pancreaticus is bleeding into the pancreatic duct and out through the ampulla of Vater, usually from a ruptured splenic artery pseudoaneurysm or another visceral aneurysm in chronic pancreatitis. It is a rare, easily missed cause of upper gastrointestinal bleeding.

It is more common in men aged 30 to 60 years with alcohol related chronic pancreatitis. The splenic artery is the source in about 60% to 75%, followed by the gastroduodenal and pancreaticoduodenal arteries. Mortality is about 20% to 25% when untreated.

Pathophysiology.

Enzymatic digestion of the arterial wall by inflamed pancreatic tissue forms a pseudoaneurysm, which erodes into the duct or into a pseudocyst that communicates with the duct.

Intermittent upper gastrointestinal bleeding (melaena or haematochezia) with epigastric pain and a history of pancreatitis. Bleeding episodes stop and restart. Shock occurs with brisk bleeding.

Red flags.

• Haemodynamic instability.
• Falling haemoglobin with negative upper endoscopy.
• Sentinel bleed from a known pseudoaneurysm.

Resuscitate first. Upper endoscopy excludes other sources and may show blood from the ampulla (side viewing endoscope). Multiphase CT angiography is the most useful test and shows the pseudoaneurysm and communication with the duct. Mesenteric angiography confirms and treats. Send full blood count, clotting and cross-match.

Differential diagnosis.

• Peptic ulcer bleeding.
• Haemobilia.
• Varices from splenic vein thrombosis.
• Aortoenteric fistula.
• Small bowel bleeding.

Resuscitate and transfuse red cells at haemoglobin 70 g/L (80 g/L with cardiovascular disease). Correct coagulopathy. Transcatheter arterial embolisation (coils, glue or covered stent) succeeds in 80% to 90% and is the first treatment. Surgery (ligation, aneurysm resection, with or without distal pancreatectomy) is for failed embolisation, instability or concurrent surgical disease.

• Pantoprazole: 40 mg IV once daily until a gastroduodenal source is excluded; maximum 80 mg daily; monitor magnesium; reduce to 20 mg daily in severe hepatic impairment.
• Prothrombin complex concentrate (anticoagulated patients with life threatening bleeding): 25 to 50 units/kg IV once; maximum 5,000 units; monitor INR at 30 minutes and for thrombosis; avoid in heparin induced thrombocytopenia.

Monitoring. Haemoglobin every 6 hours for 48 hours; repeat CT angiography at 1 to 3 months for recurrence.

Referral and escalation. Interventional radiology urgently, pancreatic surgery and critical care.