Hepatobiliary and pancreatic: Hemosuccus pancreaticus complicating calcific chronic pancreatitis

Hemosuccus pancreaticus is a term that is used to describe bleeding through the main pancreatic duct into the duodenum. The most common cause is rupture of a pseudoaneurysm of the splenic artery. This can rupture through the wall of a pseudocyst or may rupture directly into the main pancreatic duct or a larger sidebranch. Rarely, bleeding can arise from larger veins, usually in the wall of a pseudocyst. Hemosuccus pancreaticus can complicate either acute or chronic pancreatitis but the majority of reported cases have had chronic pancreatitis with pseudocyst formation. Occasionally, the diagnosis is made by the identification of bleeding through the ampulla of Vater. More often, duodenal endoscopy is normal because of intermittent bleeding or the site of duodenal bleeding remains unclear. For most patients, the next step will be a contrast-enhanced computed tomography (CT) scan. It is preferable to avoid oral contrast as this may interfere with subsequent angiography. Those patients with pseudoaneurysms or bleeding into pseudocysts should then proceed to celiac angiography, usually with embolization of the aneurysm or the splenic artery. Only a minority of patients require pancreatic surgery. The patient illustrated below was a male, aged 47 years, who was admitted to hospital because of melena. Upper gastrointestinal endoscopy and colonoscopy were normal. An upper abdominal ultrasound study revealed the unexpected finding of chronic calcific pancreatitis. Hemosuccus pancreaticus was suspected but he had a normal ampulla at repeat upper gastrointestinal endoscopy using a side-viewing endoscope. A contrast-enhanced computed tomography scan confirmed the presence of calcific chronic pancreatitis and, in addition, showed an aneurysm (arrow) of the splenic artery (Fig. 1). At angiography, a selective injection of contrast into the splenic artery confirmed the presence of an aneurysm, approximately 19 ¥ 15 mm in diameter (Fig. 2). The aneurysm was treated by embolization using 11 coils. There were no further episodes of bleeding. The diagnosis was that of direct rupture of a pseudoaneurysm into the main pancreatic duct without the presence of a pseudocyst.