Looking Beyond the Tract: An Obscure Cause of Recurrent Gastrointestinal Bleeding

Hemosuccus pancreaticus as a rare cause of gastrointestinal bleeding

Hemosuccus pancreaticus is a life-threatening condition that should be considered in patients with abdominal pain, gastrointestinal hemorrhage and high serum amylase. The varied presentation of hemosuccus pancreaticus and the limited literature evidence due to its rarity make it challenging to diagnose. Diagnostic modalities include contrast-enhanced computed tomography scans, endoscopic procedures (esophagoduodenoscopy and endoscopic retrograde cholangiopancreatography) and angiography. Therapeutic management through an interventional radiology using coil embolization is safe and effective in hemodynamically stable patients with hemosuccus pancreaticus. Endosonography can be an innovative approach for the diagnosis and treatment of patients in whom contrast cannot be administered; however, its safety and efficacy need to be confirmed by future studies. This review presents current views on the diagnosis and treatment of patients with hemosuccus pancreaticus.

Hemosuccus Pancreaticus: A systematic approach

BACKGROUND AND AIM

Hemosuccus pancreaticus is considered as one of the rare cause of upper gastrointestinal bleeding. Intermittent nature of bleeding and lack of standardized approach for diagnosis has resulted in significant delay in definitive management.

METHODS

We retrospectively analyzed prospectively maintained data of patients with suspected hemosuccus pancreaticus between January 2010 and December 2019.

RESULTS

Out of 114 patients, 87 patients were diagnosed with hemosuccus pancreaticus. Mean age was 35.7 ± 11.7 years with 89.7% men. Median duration of bleeding before diagnosis was 10 days, with 40.2%, 10.3%, and 5.7% patients had symptoms beyond 1, 6, and 12 months, respectively. Visceral artery aneurysm was noted in 62% of cases with splenic artery aneurysm (37.9%) being the common source of bleed. Rarer causes noted were superior mesenteric artery aneurysm, pancreatic adenocarcinoma, gastrointestinal stromal tumor, and post-endoscopic retrograde cholangiopancreatography (2.3% each). Santorinirrhage was seen in 3.4% patients. Endoscopic diagnosis was possible in 64.4% of patients, and angiogram localization of bleeding source was noted in 94.2%. A 56.3% of patients underwent conventional angioembolization with 95.9% success and 28.7% underwent surgery, with overall rebleeding rate of 11.5%.

CONCLUSIONS

Early diagnosis of hemosuccus pancreaticus avoids prolonged suffering, multiple hospital admissions, and multiple blood transfusions. It is not uncommon in the absence of aneurysm. In cases of high suspicion, repeating the endoscopy with proper technique and proper timing increases the yield. Angioembolization remains the most preferred first line therapeutic approach in majority of cases.