Hemosuccus Pancreaticus - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Hemosuccus pancreaticus is challenging due to its unfamiliarity to physicians and can be potentially life-threatening. It is caused by the rupture of the pseudoaneurysm of a peripancreatic blood vessel into the pancreatic duct.

What Is Hemosuccus Pancreaticus?

Gastrointestinal bleeding is very rarely caused by Hemosuccus pancreaticus. It is challenging due to its unfamiliarity to physicians and can be potentially life-threatening. It is caused by the rupture of the pseudoaneurysm (which occurs when the wall of a blood vessel is injured) of a peripancreatic blood vessel into the pancreatic duct. It can be a significant cause of confusion for doctors due to its anatomic location. The bleeding into the duodenum (the first part of the small intestine) is intermittent and cannot be diagnosed by endoscopy. Clinically, the bleeding could range from mild to severe, resulting in hypovolemic shock (an emergency condition caused by blood or other fluid loss) and death.

What Are the Other Names of Hemosuccus Pancreaticus?

The other names are:

• Pseudohemophilia.

• Hemoductal pancreatitis.

What Is the Epidemiology of Hemosuccus Pancreaticus?

• Male: Female=7:1.

• Highly associated with alcoholic excess.

• The average onset age is 50-60 years.

What Is the History of Hemosuccus Pancreaticus?

Lower and Farell reported the first case of hemosuccus pancreaticus in 1931. He reported the case of a patient with a breach in the primary splenic artery into the main pancreatic duct. Philip Sandholm named and fully explained the term in 1970 after he came across three similar cases. However, hemosuccus pancreaticus is only mentioned in a few cases in the medical literature.

What Are the Causes of Hemosuccus Pancreaticus?

The potential causes of hemosuccus pancreaticus are as follows:

1. Pancreatic inflammation: Pancreatic inflammation is the leading cause of hemosuccus pancreaticus, accounting for more than 80% of cases. Pancreatitis increases inflammatory alterations within the pancreatic duct, resulting in blood vessel ruptures. Additionally, gallbladder stones and pseudocysts (collections of leaked pancreatic fluid) in the pancreatic duct can trigger inflammatory reactions.

2. Arterial aneurysm: Aneurysm formed in the pancreatic duct is the second most common cause of hemosuccus pancreaticus. The splenic artery is the most common cause of an aneurysm in the pancreatic duct. Atheroma (fatty material collected up in the blood vessel), congenital connective tissue disorders like Marfan syndrome and Ehlers-Danlos syndrome, fibromuscular dysplasia (a condition that causes narrowing and enlargement of blood vessels), vasculitis (inflammation of blood vessels), etc. can be the causes of the aneurysm.

3. Pancreatic tumors: Both benign (such as serous cystic and mucinous cystic neoplasms) and malignant (such as pancreatic carcinoma and neuroendocrine tumors) have been linked to hemosuccus pancreaticus.

4. Iatrogenic: Hemosuccus pancreatitis is also caused by complications from fine needle aspiration biopsy, pancreatic stenting, endoscopic ultrasound, and other procedures.

5. Infectious process: Infections such as brucellosis and syphilis have been linked to hemosuccus pancreaticus.

6. Congenital anomalies: Heterotopic pancreas and pancreatic divisum can cause a recurrent sequence of pancreatitis, which can get complicated to cause hemosuccus pancreaticus.

How Is Hemosuccus Pancreaticus Diagnosed?

The diagnosis of hemosuccus pancreaticus can be very challenging because it is uncommon, has a difficult anatomic location, and has an intermittent nature of bleeding.

1. A thorough case history can identify the potential risk factors and the causative factors.

2. Clinical presentation: Abdominal pain radiating to the back and melena (dark sticky feces and partially digested food) is the most common clinical presentation. The pain may not be severe enough to make the patient unconscious. Symptoms of upper or lower gastrointestinal tract bleeding can also be observed. Despite its arterial origin, bleeding may not be very severe. Other symptoms can include vomiting, jaundice, and weight loss.

3. Laboratory investigation: If pancreatitis is the cause, elevated serum bilirubin, amylase, and lipase levels can be found in the lab. Other laboratory tests can be normal and non-conclusive.

4. Imaging tests: When GI (gastrointestinal) bleeding is observed, endoscopy is compulsory to rule out common causes of GI bleeding like peptic ulcer, erosive gastritis, etc. Endoscopes that provide side views like ERCP (endoscopic retrograde cholangiopancreatography) can help detect and visualize the source of bleeding. Abdominal ultrasound can help identify an aneurysm or a pseudocyst. A contrast-enhanced CT (computed tomography) is an excellent imaging technique for diagnosing pancreatic pathologies. Angiography is the ultimate diagnostic standard. It can help identify the causative artery.

How Is Hemosuccus Pancreaticus Treated?

In GI bleeding patients, irrespective of whether it is in the upper or lower GI tract, the first step is assessing how severe the bleeding is and resuscitating the patient, followed by proper monitoring of the condition. To treat unstable hemosuccus pancreaticus, oxygen therapy, 2 IV bore needles with fluid administration, and blood transfusion preparation is used. Patients receiving only supportive therapy have a 90% mortality rate. The next step is identifying the source of bleeding using imaging techniques, followed by definitive therapy. The main goal in managing the condition is to stop the bleeding.

The two main techniques involved in managing the condition are interventional radiology (IR) and open surgery. The option chosen depends on the patient’s clinical presentation.

• Interventional radiologist: It is usually performed in hemodynamically stable patients and is the first line of treatment in hemosuccus pancreaticus. The procedure includes angiography with embolization through a prosthetic material, balloon tamponade, or stent placement. Coil embolization is commonly used to induce thrombi within the aneurysmal vessels. Coil embolization is a procedure to reduce the blood flow through a blood vessel. This method has a 30% recurrence of the bleeding following embolization.

• Surgical interventions: Surgical interventions with laparoscopy include distal pancreatectomy and splenectomy, central pancreatectomy, an intracystic fusing of the blood vessels, aneurysm ligation, and the bypass graft. They are usually considered in patients with unstable blood pressure.

What Are the Differential Diagnosis of Hemosuccus Pancreaticus?

• Peptic ulcer.

• Gastritis and duodenitis.

• Esophageal varices.

• Esophagitis.

• Upper GI tumors.

• Portal hypertension gastropathy

• Diverticulosis.

• Angiodysplasia.

• Inflammatory bowel diseases.

• Benign or malignant tumors.

• Infectious colitis.

• Ischemic colitis.

How Can Hemosuccus Pancreaticus Be Prevented?

Patients with chronic pancreatitis are advised to avoid alcohol and smoking to prevent the condition's progression. A low-fat diet, rich in protein and carbohydrates, is recommended. Fat-soluble vitamins and pancreatic enzyme supplements should be strictly followed. Annual screening for diabetes mellitus and osteoporosis is also required.

Conclusion

Hemosuccus pancreatitis is a life-threatening and challenging condition. Although early diagnosis is challenging, using appropriate diagnostic tools can help immensely in decreasing the mortality rate.