Haemosuccus pancreaticus, also known as pseudohaemobilia or haemoductal pancreatitis, is defined as upper gastrointestinal tract haemorrhage originating from the pancreatic duct into the duodenum via the ampulla of Vater, or major pancreatic papilla.
- male:female ratio is 7:1
- highly correlated with chronic alcohol abuse
- mean age of onset: 50-60 years 1
- only ~100 reported cases in the literature between 1967 and 2011
A triad of epigastric pain, intermittent gastrointestinal bleeding and hyperamylasaemia 1,2.
The most common aetiology is pseudoaneurysm rupture of the splenic (60-65%)1, gastroduodenal or duodenopancreatic artery. Pseudoaneurysm formation is most commonly secondary to chronic pancreatitis and occurs in 10% of this population.
Chronic local inflammation is thought to lead to an increased local release of elastase, with either autodigestion of peripancreatic vessels or erosion of a concomitant pseudocyst into the artery 3.
From most common to least common:
- peripancreatic tumour haemorrhage
- primary vascular aneurysm
- iatrogenic: complication of biopsy/FNA, pancreatic duct stenting, or ERCP
- congenital abnormality
- infection: chronic pancreatitis, brucellosis, syphilis
Ultrasonography can help visualise peripancreatic artery pseudoaneurysms and pancreatic pseudocysts. Real-time Doppler interrogation is a sensitive method for demonstrating intermittent haemorrhage. 8
CT angiography (CTA) may show the culprit pseudoaneurysm or pseudocyst, possibly demonstrating active bleeding, along with hyperdense material (i.e. fresh blood, clots) in the pancreatic ducts. In addition, it can visualise other relevant pathology, which can help narrow down the differential diagnosis 9.
If employed at the time of active bleeding, ERCP can afford direct visualisation of blood seeping through the papilla by means of using a side-viewing endoscope (duodenoscope).
As haemorrhage is often intermittent, direct selective angiography is superior in identifying small arterial filling defects and for the identification of small pseudoaneurysms or fistulae 5,6,8.
Angiography is also used therapeutically (see below).
Radionuclide 99mTc red blood cell scintigraphy is of low diagnostic yield 1.
Treatment and prognosis
- angiography, with or without coil embolization 4,6
- surgical debridement and ligation 3: in severe cases, with or without pancreaticoduodenectomy 5
- 90% mortality rate in patients treated with supportive therapy only 5
History and etymology
First reported in 1931, and later described by P Sandholm in 1970, who reported three patients with gastrointestinal bleeding from pancreatic duct pseudoaneurysm rupture, and coined the term. 7
- 1. Han B, Song ZF, Sun B. Hemosuccus pancreaticus: a rare cause of gastrointestinal bleeding. Hepatobiliary & pancreatic diseases international : HBPD INT. 11 (5): 479-88. Pubmed
- 2. Sakorafas GH, Sarr MG, Farley DR, Que FG, Andrews JC, Farnell MB. Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper gastrointestinal bleeding. Langenbeck's archives of surgery. 385 (2): 124-8. Pubmed
- 3. Stanley JC, Frey CF, Miller TA, Lindenauer SM, Child CG. Major arterial hemorrhage: a complication of pancreatic pseudocysts and chronic pancreatitis. Archives of surgery (Chicago, Ill. : 1960). 111 (4): 435-40. Pubmed
- 4. De Rosa A, Gomez D, Pollock JG, Bungay P, De Nunzio M, Hall RI, Thurley P. The radiological management of pseudoaneurysms complicating pancreatitis. JOP : Journal of the pancreas. 13 (6): 660-6. Pubmed
- 5. Tabrizian P, Newell P, Reiter BP, Heimann TM. Successful multimodality treatment for hemosuccus pancreaticus. The American journal of gastroenterology. 104 (4): 1060. doi:10.1038/ajg.2009.33 - Pubmed
- 6. Sul HR, Lee HW, Kim JW, Cha SJ, Choi YS, Kim GH, Kwak BK. Endovascular management of hemosuccus pancreaticus, a rare case report of gastrointestinal bleeding. BMC gastroenterology. 16: 5. doi:10.1186/s12876-016-0418-3 - Pubmed
- 7. Sandblom P. Gastrointestinal hemorrhage through the pancreatic duct. Annals of surgery. 171 (1): 61-6. Pubmed
- 8. Benz CA, Jakob P, Jakobs R, Riemann JF. Hemosuccus pancreaticus--a rare cause of gastrointestinal bleeding: diagnosis and interventional radiological therapy. Endoscopy. 32 (5): 428-31. doi:10.1055/s-2000-638 - Pubmed