Hemosuccus pancreaticus

Last revised by Raymond Chieng on 1 Jun 2023

Hemosuccus pancreaticus, also known as pseudohaemobilia or hemoductal pancreatitis, is a rare cause of GI bleeding, due to blood 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 excess
  • mean age of onset: 50-60 years 1
  • only ~100 reported cases in the literature between 1967 and 2011
  • 1 in 1500 cases of gastrointestinal hemorrhage 10

A triad of epigastric pain, intermittent gastrointestinal bleeding and hyperamylasemia 1,2.

The most common etiology is pseudoaneurysm rupture of the splenic (60-65%)1, gastroduodenal or pancreaticoduodenal 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:

  • pancreatitis (80% cases 10)
  • peripancreatic tumor hemorrhage
  • primary vascular aneurysm
  • iatrogenic: complication of biopsy/FNA, pancreatic duct stenting, ERCP, bariatric surgery 9
  • congenital abnormality
  • trauma
  • infection: chronic pancreatitis, brucellosis, syphilis

Ultrasonography can help visualize peripancreatic artery pseudoaneurysms and pancreatic pseudocysts. Real-time Doppler interrogation is a sensitive method for demonstrating intermittent hemorrhage 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 visualize other relevant pathology, which can help narrow down the differential diagnosis ref.

If employed at the time of active bleeding, ERCP can afford direct visualization of blood seeping through the papilla by means of using a side-viewing endoscope (duodenoscope).

As hemorrhage 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 99m-Tc red blood cell scintigraphy is of low diagnostic yield 1.

  • 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

First reported in 1931, and later described by a Swedish surgeon, Philip Sandblom (1903-2001) 11 in 1970, who reported three patients with gastrointestinal bleeding from pancreatic duct pseudoaneurysm rupture, and coined the term "hemosuccus pancreaticus" 7.

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Cases and figures

  • Hemosuccus pancreaticus
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  • Hemosuccus pancreaticus pre and post embolization of SMA
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