A Rare Cause of Upper Gastrointestinal Bleeding:
Hemosuccus Pancreaticus: Angiographic
and Endoscopic Combined Treatment
Abdurrahim Sayilir, MD,* Ibrahim K. Onal, MD,* Yavuz Beyazit, MD,*
Ali Surmeliog˘lu, MD,w R. Salper Okten, MD,z Bulent Odemis, MD,*
Erkan Parlak, MD,* and Nurgul Sasmaz, MD*
Abstract: Hemosuccus pancreaticus (HP) is a rare cause of upper
gastrointestinal bleeding. Pancreatitis are the most common cause
of HP. Here, we report the case of a 48-year-old male with HP due
to alcohol-induced chronic pancreatitis. Superior mesenteric
angiography showed an inferior pancreaticoduodenal artery
pseudoaneurysm. The patient underwent coil embolization for
treatment of his pseudoaneurysm. Endoscopic retrograde cholan-
giopancreatography and pancreatic stents replacement was per-
formed for pancreatic pseudocyst drainage. In patients with HP,
angiographic and endoscopic combined treatment can protect from
the risks of surgery.
Key Words: hemosuccus pancreaticus, pseudoaneurysm, endo-
scopic retrograde cholangiopancreatography, angiography
(Surg Laparosc Endosc Percutan Tech 2011;21:e286–e287)
into the gastrointestinal tract through the ampulla of Vater
usually due to a communication between one of the
branches of a visceral artery and Wirsung duct. Chronic
and acute pancreatitis are the most common cause of
HP.1–3We present a case of HP treated with angiographic
and endoscopic combined technique.
emosuccus pancreaticus (HP) is a rare cause of upper
gastrointestinal bleeding in which blood loss occurs
A 48-year-old man with a history of alcohol-induced
pancreatitis was referred to our clinic for evaluation of melena
and abdominal pain that had occurred in the last 8 days. He had
undergone upper endoscopic and colonoscopic examinations in
another hospital but endoscopic examinations failed to demon-
strate the origin of the bleeding. In the computed tomography (CT)
scan, only positive finding was a 50mm cystic lesion at the
pancreatic head. Physical examination revealed tachycardia of
110bpm and a systolic blood pressure of 100mm Hg. A full blood
count revealed 7.6g/dL (normal values; 13.6 to 17.2) with normal
platelets and prothrombin time. The patient was resuscitated with
crystalloids and 2 units packed red blood cells. After achieving a
stable hemodynamic state, because of active bleeding urgent upper
gastrointestinal endoscopy was performed again in our canter. The
endoscopy showed active bleeding coming out of papilla. In the
light of these findings, thought to be HP, angiography of the celiac
axis and superior mesenteric artery was performed. Angiography
identified pseudoaneurysms that filled from the inferior pancrea-
ticoduodenal artery. The coil embolization of the inferior pan-
creaticoduodenal artery was successfully performed (Figs. 1A, B).
A new CT scan of abdomen with intravenous contrast demon-
strated dilated pancreatic duct, 7cm pseudocyst adjacent to tale-
body and an another cyst that have air and contrast agent adjacent
to head and uncinate process of the pancreas (Fig. 2A). Endoscopic
retrograde cholangiopancreatography was performed to evaluate
for connection between pseudocyst and dilated pancreatic duct.
The pancreatic duct was dilated and there was a 3cm cysts
associated with one of the side branches. Two pancreatic stents
(7F, 7cm) were placed (Figs. 3A, B). After 15 days, the patient was
discharged. Two months after the discharge, control abdominal CT
scan showed no cyst around the pancreas (Fig. 2B).
Firstly, a splenic artery aneurysm communicating with
the pancreatic duct was found by Lower and Farrell4in a
16-year-old boy who complained of melena and abdominal
pain for several years in 1931. But the term “HP,” was
defined by Sandblom in 1970.1
Pseudoaneurysms of peripancreatic arteries may arise
as a complication of acute or chronic pancreatitis and can
result in life-threatening hemorrhage. The splenic artery is
the most commonly involved, followed in decreasing order
of frequency by gastroduodenal, pancreaticoduodenal,
FIGURE 1. A, Angiography identified pseudoaneurysms (white
arrow) that filled from the inferior pancreaticoduodenal artery,
(B) after embolization of the inferior pancreaticoduodenal artery
with coil (black arrow), the leak was stopped.
Received for publication January 27, 2011; accepted March 14, 2011.
From the *Departments of Gastroenterology; wGastrointestinal Sur-
gery; and zRadiology, Turkiye Yuksek Ihtisas Teaching and
Research Hospital, Ankara, Turkey.
The authors declare no conflict of interest.
Reprints: Abdurrahim Sayilir, MD, Department of Gastroenterology,
Turkiye Yuksek Ihtisas Teaching and Research Hospital, Kizilay Sk.
No: 2, TR-06100 Sihhiye, Ankara, Turkey (e-mail: drabdurrahim@
Copyrightr2011 by Lippincott Williams & Wilkins
e286|www.surgical-laparoscopy.com Surg Laparosc Endosc Percutan Tech?Volume 21, Number 5, October 2011
hepatic, and left gastric arteries.5,6Other unusual causes of
HP include tumors, arteriovenous malformations, and
complication of endoscopic ultrasound guided fine needle
Treatment options for HP include surgery and
interventional radiology. Angiography is used for both
diagnosis and treatment. It is the gold standard for
diagnosis and for characterizing the exact anatomic site.8,9
When embolization fails or is unavailable or there is
recurrence of bleeding after embolization, surgical treat-
ment is required.
If patients with pancreatitis present with gastrointest-
inal bleeding, HP should be included in differential
diagnosis. In these patients, angiographic and endoscopic
combined treatment can protect from the risks of
pancreatic duct. Ann Surg. 1970;171:61–66.
2. Bivins BA, Schatello CR, Chuang VP, et al. Haemosuccus
pancreaticus (haemoductal pancreatitis): gastrointestinal he-
morrhage due to rupture of a splenic artery aneurysm into the
pancreatic duct. Arch Surg. 1978;113:751–753.
3. Cahow CE, Gusberg RJ, Gottlieb LJ. Gastrointestinal haemor-
rhage from pseudoaneurysm in pancreatic pseudocysts. Am J
4. Lower WE, Farrell JI. Aneurysm of the splenic artery: report of
a case and review of the literature. Arch Surg. 1931;23:182–190.
5. Bender JS, Bouwman DL, Levison MA, et al. Pseudocysts and
pseudoaneurysms: surgical strategy. Pancreas. 1995;10:143–147.
6. Negi SS, Sachdev AK, Bhojwani R, et al. Experience of surgical
management of pseudoaneurysms of branches of the coeliac axis
in a North Indian hospital. Trop Gastroenterol. 2002;23:97–100.
7. Singh P, Gelrud A, Schmulewitz N, et al. Hemosuccus
pancreaticus after EUS-FNA of pancreatic cyst (with video).
Gastrointest Endosc. 2008;67:543.
8. Mandel SR, Jaques PF, Sanofsky S, et al. Nonoperative
management of peripancreatic arterial aneurysms: a 10-year
experience. Ann Surg. 1987;205:126–128.
9. Sugiki T, Hatori T, Imaizumi T, et al. Two cases of hemosuccus
pancreaticus in which hemostasis was achieved by transcatheter
arterial embolization. J Hepatobiliary Pancreat Surg. 2003;10:
P. Gastrointestinal hemorrhagethrough the
FIGURE 2. A, Computed tomography (CT) scan of abdomen
demonstrated 7cm pseudocyst (white arrow) adjacent to tale-
body and an another cyst (black arrow) that have air and contrast
agent adjacent to head and uncinate process of the pancreas, (B)
control abdominal CT scan showed no cyst around the pancreas.
FIGURE 3. A, An endoscopic retrograde cholangiopancreatogra-
phy showed that there was a dilated pancreatic duct and a 3cm
cyst (arrow) adjacent to the coil. B, Two pancreatic stents were
Surg Laparosc Endosc Percutan Tech?Volume 21, Number 5, October 2011Hemosuccus Pancreaticus
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