Collapse, melena, Hb 50
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Cachexia is consistent with his history of end-stage renal failure and malnutrition. There are numerous pseudocysts in relation to the pancreas and stomach. A small dense focus of contrast enhancement is seen within a cyst in the body of the pancreas best in arterial phase, which becomes less dense on the portal venous and delayed phases.
A large pseudocyst extends through the epiploic foramen and is new compared with previous imaging. Inferiorly, the cyst extends to the right of the aorta to the right common iliac bifurcation, anterior to the IVC. Superiorly, the cyst extends to the porta hepatis, posterior to the portal vein bifurcation. It contains some high-density material suggestive of recent bleed.
The pancreatic cyst appearance and the clinic history is suspicious for a small aneursym or pseudo-aneursym causing intermittent arterial bleeding into the cyst, and through the pancreatic duct into the duodenum (haemosuccus pancreaticus).
This man was brought to hospital via ambulance following a collapse at home, on a background of end-stage kidney disease secondary to hypertension, on haemodialysis, and an episode of gallstone pancreatitis 3 months ago, complicated by complex pancreatic pseudocysts.
In the emergency department, he was found to be hypotensive, with a Hb of 50g/L, tender epigastrium and copious melena, on per-rectal examination. He underwent red cell transfusion and an upper gastrointestinal endoscopy the next day that found no evidence of active bleeding. His hemoglobin remained stable for several days, and a colonscope found no source of bleeding either. He proceeded to capsule endoscopy, which revealed fresh blood in the first part of the duodenum, and a mucosal lesion suspicious for malignancy, which was thought to be the source of the bleeding. A repeat endoscopy and biospy subsequently proved the lesion to be benign.
Several days into the admission, the patient passed more melena and his hemoglobin dropped precipitously from 90g/L to 60g/L. A multiphase CT angiogram of the abdomen including a delayed venous phase was performed. A small pseudo-aneurysm was seen on the arterial phase within one of the pancreatic pseudocysts and appeared to be communicating with the pancreatic duct. As the patient stabilized there was no indication for repeat upper gastrointestinal endoscopy to confirm the diagnosis of haemosuccus pancreaticus.
Thanks to Dr Craig Hacking, Dr Sonja Gustafson, Dr Greg Wilson and Dr James Rowland
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