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

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


May 11, 2016

Establishing the diagnosis requires clinical suspicion in patients with a medical history of chronic pancreatitis who present with GI bleeding and severe anemia. This may be manifested primarily as intermittent melena without associated hematemesis, although frank hematochezia may occur.[6,10] More insidious presentations have been described with anemia and vague abdominal discomfort, which may indicate intraperitoneal bleeding and/or bleeding within the pseudocyst. Other exceptional forms of presentation include jaundice, nausea with and without vomiting, and a palpable pulsating mass.[2,3,4]

The differential diagnosis of hemosuccus pancreaticus is broad and includes other causes of acute upper GI bleeding. Depending on the clinical presentation of the individual patient, other considerations include peptic ulcer disease, esophageal varices, arteriovenous malformations, Mallory-Weiss tears, and tumors. Because bleeding may be intermittent with an initial endoscopic evaluation, relatively obscure causes may also be included in the differential, such as Dieulafoy lesion, aortoenteric fistula, and true hemobilia of biliary origin.[8]

Following hemodynamic stabilization of the patient, the initial workup should be aimed at identifying the source of bleeding. Esophagogastroduodenoscopy (EGD) can rule out other causes of upper GI bleeding and may identify the presence of blood clots in the duodenum in the setting of pseudohemobilia[8]; however, active bleeding from the ampulla of Vater is rarely seen because of the intermittent nature of the bleeding. Use of a side-viewing endoscope may help with the visualization of active bleeding from the ampulla of Vater. CT scanning, CT angiography, MRI, and magnetic resonance angiography (MRA) may provide information regarding the presence of a fistula between a peripancreatic aneurysm or pseudoaneurysm and the pancreatic duct, as well as identify the presence of a "sentinel clot"[11] (focal, high-density clotted blood) in the pancreatic duct during episodes of intermittent bleeding.[12]

Doppler studies performed percutaneously or by endoscopic ultrasonography may be useful in identifying the presence of pancreatic pseudocysts as well as any aneurysmal mass. ERCP may demonstrate the presence of clots in the pancreatic duct as well as pancreatic duct dilation and pseudocyst filling, if present. Finally, a pancreatoscopy can be performed using a mother-daughter system endoscope in select centers. Technetium Tc 99m-labeled red blood cell scintigraphy may help identify the location of the bleeding during periods of active bleeding.[12]

Angiography is potentially useful as a part of early diagnostic and therapeutic management strategies, especially in the setting of significant GI bleeding of obscure origin (which is typical in the setting of hemosuccus pancreaticus).[12] Selective angiography of the celiac trunk and the superior mesenteric artery allows for characterization of the anatomic origin of a hemorrhage, as well as identification of any aneurysms or pseudoaneurysms that may be present. It also allows for therapeutic intervention with gel foam or coil embolization of the involved arterial segments.[6,10,12] Additionally, interventional radiologic therapy with the use of a bare metal stent across a splenic artery aneurysm has been described.[10]


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