A Rare Cause of Upper Gastrointestinal Bleeding

1University of Texas Health Science Center at San Antonio, San Antonio, TX
2University of Texas Health Science Center at San Antonio, San Antonio, TX
3University of Texas Health Science Center at San Antonio, San Antonio, TX
4University of Texas Health Science Center at San Antonio, San Antonio, TX

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 464

Case Presentation:

A 56‐year‐old woman presented with severe abdominal pain, nausea, vomiting, fever, and hypotension. Admission laboratory tests were significant for serum amylase 420 IU/L (17–95 IU/L) and serum lipase 292 IU/L (12–84 IU/L). Computed tomography of the abdomen revealed no abnormalities. Two days after admission the patient's condition was stable, but she continued to complain of intermittent abdominal pain. Over 1 week her serum hemoglobin decreased from 13.1 g/dL to 6.9 g/dL Esophagogastroduodenoscopy revealed blood in the duodenum. By introduction of a side viewing endoscope, both a major and minor pancreatic papilla were identified consistent with pancreas divisium. Bleeding was noted from the minor papilla. Celiac angiography demonstrated a duplicated gastroduodenal artery with extravasation from the distal branches, which were coil embolized. Three weeks later, the pain and hematochezia returned. Repeat computed tomography demonstrated a pseudocyst in the peripancreatic area and a chronic hematoma within the liver, neither of which had been seen in previous studies. The patient declined further interventions due to her poor prognosis and multiple comorbidities.

Discussion:

Abdominal pain and gastrointestinal bleeding are common complaints among hospitalized patients. Hemosuccus pancreaticus, or bleeding from the pancreatic duct, is a cause of this bleeding and can be overlooked given its rarity. Hemosuccus pancreaticus is often due to chronic pancreatitis, pancreatic pseudocysts, trauma, pancreatic tumors, bleeding from arteriovenous malformations and pancreas divisum. Hemosuccus pancreaticus usually presents with abdominal pain and symptoms of gastrointestinal bleeding, which can be life threatening. More than 50% of patients will have mid‐epigastric crescendo‐decrescendo abdominal pain, which may be due to transient blockage of the pancreatic duct from the source of bleeding or clots. The diagnosis of hemosuccus pancreaticus is challenging. A forward‐viewing endoscope may not reveal bleeding due to the lateral anatomic location of the pancreatic duct orifice. A side‐viewing endoscope may be used to localize the bleeding. Computed tomography can be helpful by demonstrating specific pathologies, including pancreatitis, pancreatic tumor, and pseudocyst. Angiography may be performed to determine which vessel is the cause of the bleeding provided the bleeding is brisk. Because the bleeding is intermittent, endoscopy may not reveal hemorrhage. In this case, hemorrhage was visualized at the minor papilla. The first line of treatment is embolization; however, if angiography is unsuccessful, pancreatectomy will be the only option.

Conclusions:

Hemosuccus pancreaticus is a rare cause of abdominal pain and gastrointestinal bleeding. Although it is rare, keeping it in the differential diagnosis may keep lead to earlier treatment and reduce morbidity and mortality. Here we report a case of pancreas divisum as the cause of hemosuccus pancreaticus.

Image from side‐viewing endoscope. A: Active bleeding from minor papilla. B: Major papilla.

To cite this abstract:

Nassar T, Kour M, Hanson J, Moreland C. A Rare Cause of Upper Gastrointestinal Bleeding. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 464. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-rare-cause-of-upper-gastrointestinal-bleeding/. Accessed May 22, 2019.

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