The diagnosis of haemosuccus pancreaticus relies on clinical evaluation, upper gastrointestinal endoscopy and medical imaging. Endoscopy is essential to rule out other causes of upper gastrointestinal bleeding. Bleeding from the ampulla may be visualised, confirming either haemobilia or haemosuccus pancreaticus. As demonstrated in previous series, a negative endoscopy is present in 70% of cases. 5,7,8
Medical imaging plays an integral role in the diagnosis of haemosuccus pancreaticus. Contrast enhanced computed tomography is the most valuable first line radiological modality as it demonstrates pancreatic pseudocyst and pseudoaneurysm, as well as other local complications of pancreatitis. Simultaneous opacification of an aneurysmal artery and pseudocyst, or contrast persistence in a pseudocyst following the arterial phase are suggestive of the diagnosis. 8,9 The diagnosis must also be considered when a pseudoaneurysm is present within or adjacent to a pseudocyst.7 The “sentinal clot” sign where blood products are directly visualised within the pancreatic duct on pre-contrast images is rarely seen. 1,3,5 Ultrasonography may aid in diagnosis of pancreatic pseudoaneurysm, however it offers minimal additional information in the presence of contrast enhanced CT. Radionuclide labeled red cells also contribute marginally due to the intermittent nature of the bleeding.7
Angiography remains the most reliable modality in the diagnosis with the additional benefit of offering simultaneous interventional management. One case series, comprising of 26 patients, showed that angiography was able to detect the causative vessel in 88% of patients. 6 Direct contrast extravasation into the pancreaticobiliary system or pseudocyst may be demonstrated and support the diagnosis, however this is not commonly present. 6,7
The therapeutic options in haemosuccus pancreaticus generally include surgery and angiographic embolisation. Embolisation is first line for both definitive management or as a temporizing measure prior to surgery. Success rates of 60-100% with approximately 30% rebleeding following embolization have been reported.3,10,11 Surgical management is required in acutely haemodynamically unstable patients, following unsuccessful embolization, and in patients who have concurrent surgical pathology. Common surgical options include arterial ligation, aneurysmal ligation and bypass graft, distal pancreatectomy or pancreaticoduodenectomy. 3,8
Case report:
A 28-year-old Indigenous gentleman was admitted to hospital with acute on chronic alcohol induced pancreatitis. Unfortunately, the patient developed intermittent haematemesis on day 10 of admission. Endoscopy failed to reveal the source of the patient’s haemorrhage. There was no bleeding from the duodenal papilla visualised.
Worsening of the patient’s gastrointestinal bleeding prompted a CT angiogram to be performed, which demonstrated a 21x15mm pancreatic head pseudoaneurysm arising from superior and inferior pancreaticoduodenal arteries with surrounding low density intrapancreatic tissue likely representing fluid collection or blood products. (Figure 1) Incidentally there was a replaced right hepatic artery and severe coeliac stenosis. (Figure 2, Figure 3) The patient proceeded to angiography post stabilisation for attempted embolisation whilst the surgical team remained on standby. Selective cannulation of the inferior pancreaticoduodenal artery via the superior mesenteric artery revealed contrast extravasation into what was believed to be the common bile duct and pancreatic duct. (Figure 4) Via the superior mesenteric artery, the backdoor inferior pancreaticoduodenal feeding vessel was selectively cannulated and coiled. (Figure 5) The front door superior pancreaticoduodenal artery arising from both the gastroduodenal artery and replaced right hepatic was then coiled. (Figure 6) A follow up triple phase CT demonstrated successful coiling of the pseudoaneurysm and the patient suffered no further gastrointestinal bleeding. Similar to other cases reported in the literature, the diagnosis of haemosuccus pancreaticus was not completely certain, but was the consensus among clinicians involved.