Hemosuccus pancreaticus associated with splenic artery aneurysms and hepatic artery thrombosis late after liver transplantation.

We read with interest the article by Ray S. et al. recently published in JOP. Journal of the Pancreas [1]. We agree with authors that given the rarity and intermittent course of hemosuccus pancreaticus, difficulties in determining the location of bleeding sometimes cause delay of treatment. Until now, reports on hemosuccus pancreaticus in transplant population have been quite limited. Therefore, we would like to present the experience of hemosuccus pancreaticus in a liver transplant patient and comment on problems and pitfalls of a post-transplant setting. Herein, we report a case of a 58-year-old man evaluated for endoscopy negative 7-day melena and acute pancreatitis. Four years before the patient underwent liver transplantation with Roux-en-Y hepaticojejunostomy, with unremarkable follow-up, which routinely included Doppler ultrasound once a year. His therapy consisted of cyclosporine and mycophenolate mophetil. One day after admission, the occurrence of hematemesis urged repeated endoscopy, which revealed the fresh blood originating from the papilla of Vater (Figure 1). Endoscopic retrograde cholangiopancreatography was performed, demonstrating patent pancreatic duct and blind remnant of native common bile duct without communications between pancreaticobiliary tract and blood vessels. During the procedure few blood clots originated from the papilla of Vater. Multislice contrast computed tomography showed moderate enlargement of the pancreatic head with suspected hematoma (Figure 2), along with three splenic artery aneurysms, of 30 mm, 12 mm and 8 mm in diameter, in the distal arterial segment, as well as anastomotic stenosis of native and donor hepatic artery. However, contrast extravasation on visceral angiography was not detected (Figure 3). The embolization of the splenic artery aneurysms was judged unfeasible due to tortuosity of the splenic artery, wide neck of the major aneurysm and proximity of other two aneurysms to the splenic hilum. Supportive therapy stabilized the patient and gastrointestinal bleeding resolved. The patient was scheduled for surgery; however, subsequent development of hepatic artery thrombosis, resulted in multiple liver abscesses and septic episodes