A 47-Year-Old Man With a History of Alcohol-Induced Chronic Pancreatitis

Juan Carlos Munoz, MD; William J. Salyers, Jr, MD, MPH

Disclosures

May 11, 2016

Discussion

The diagnosis of hemosuccus pancreaticus was made at the time the upper endoscopy was performed following hemodynamic stabilization of the patient. Using a side-viewing endoscope, active bleeding from the ampulla of Vater was visualized (see Figure). In the clinical setting of chronic pancreatitis with a large communicating pancreatic pseudocyst following the recent ERCP, this finding established the diagnosis.

Hemosuccus pancreaticus, also known as wirsungorrhagia or pseudohemobilia,[1] is a rare syndrome of bleeding into the pancreatic duct manifested by blood loss through the ampulla of Vater. The first case was described in 1931 by Lower and Ferrell[2]; and, in 1969, Vankemmel proposed the term "wirsungorrhagia" (currently used in France).[3] In 1970, Sandblom published 3 cases and coined the term "hemosuccus pancreaticus" to describe the similarity of the disorder to the clinical syndrome of hemobilia.[4]

Overall, hemosuccus pancreaticus is a rare clinical entity with a frequency of only 1 out of 1500 gastrointestinal (GI) bleeding cases, and less than 100 cases have been reported in the medical literature.[3,5] It most commonly occurs in the setting of chronic pancreatitis with and without pancreatic pseudocysts. It is also seen with acute pancreatitis, neuroendocrine tumors, ectopic pancreas, pancreas divisum, and pancreatolithiasis, as well as being reported as a complication of ERCP and following traumatic abdominal pseudoaneurysm formation.[3,6,7] Hemosuccus pancreaticus usually develops following the rupture of an aneurysm or pseudoaneurysm, which develops in the setting of both pressure necrosis and autodigestion from pancreatic enzymes that lead to progressive vessel wall thinning.[8,9] The splenic artery is most commonly affected (60%-65% of cases), followed by the gastroduodenal artery.[9] Pancreaticoduodenal artery involvement occurs in only 10%-15% of cases, with hepatic artery and left gastric artery involvement also having been reported.[9] Mortality rates as high as 57% have been reported with pseudocyst-associated rupture of pseudoaneurysms.[9]

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