Rare Presentation of a Massive Intermittent Upper Gastrointestinal Bleed

Introduction: Hemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding defined as bleeding from the ampulla of Vater through the main pancreatic duct, commonly caused by a ruptured aneurysm in the setting of acute or chronic pancreatitis. Bleeding is often intermittent and repetitive, but can be massive. Endoscopy rarely reveals active hemorrhaging. Case Report: We present a 35-year-old male with complaints of progressive fatigue and generalized weakness over two weeks. He denied melena, hematochezia, and hematemesis. History revealed prior alcohol abuse and hospitalization for pancreatitis. Laboratory studies revealed hemoglobin of 2.8 g/dL. Initial esophagogastroduodenoscopy (EGD) revealed actively bleeding mass at the major papilla and absence of gastric/esophageal varices. Colonoscopy revealed no pathology. Bleeding continued and patient developed mild epigastric tenderness. Repeat EGD revealed a clean based ulcer in the distal esophagus and thickening of the duodenal mucosa, but no bleeding. Duodenal biopsies showed signs of chronic inflammation. Abdominal computed tomography scan revealed pancreatitis and splenic artery pseudoaneurysm. Patient underwent an abdominal aortogram, revealing an 8 mm splenic artery pseudoaneurysm with no active bleeding. The pseudoaneurysm was embolized and repeat imaging confirmed no residual pseudoaneurysm. Conclusion: Pseudoaneurysm resulting from a pseudocyst secondary to pancreatitis forms most commonly in the splenic artery. Mortality can be as high as 90–100% if left untreated. Although rare, hemosuccus pancreaticus should be included in the differential diagnosis for any patient presenting with severe anemia, in the absence of endoscopically visualized bleeding and with a history of pancreatitis. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 8 No. 1, January 2017. ISSN – [0976-3198] Int J Case Rep Images 2017;8(1):30–35. www.ijcasereportsandimages.com Patek et al. 30 CASE REPORT OPEN ACCESS Rare presentation of a massive intermittent upper gastrointestinal bleed Bonnie Patek, Matthew Sullivan, Shashin Shah