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Hemosuccus pancreaticus due to a small arterial pseudoaneurysm detected by CE-EUS and successfully treated with angiographic coiling (with video)


1 Department of Gastroenterology, Oncology and Diabetology, Theresien Hospital and St. Hedwig Clinics, Mannheim, Germany
2 Department of Radiology, Theresien Hospital and St. Hedwig Clinics, Mannheim, Germany

Date of Submission07-Sep-2020
Date of Acceptance02-Nov-2020
Date of Web Publication09-Feb-2021

Correspondence Address:
Daniel Schmitz,
Department of Gastroenterology, Oncology and Diabetology, Theresien Hospital and St. Hedwig Clinics, University of Heidelberg, Bassermannstr. 1, 68165 Mannheim
Germany
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-20-00199

PMID: 33586690



How to cite this URL:
Schmitz D, Hansmann J, Rudi J. Hemosuccus pancreaticus due to a small arterial pseudoaneurysm detected by CE-EUS and successfully treated with angiographic coiling (with video). Endosc Ultrasound [Epub ahead of print] [cited 2021 Jun 24]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=308928

In hemosuccus pancreaticus,[1] potentially life-threatening bleeding into the pancreatic duct is usually caused by a large arterial pseudoaneurysm (average size of 52 mm) in chronic pancreatitis.[2] Bleeding from the papilla can be seen by endoscopy, and pseudoaneurysm can be detected by standard cross-sectional imaging. In this case report, a small pseudoaneurysm of the splenic artery with a fistula to the pancreatic duct could only be discovered by contrast-enhanced EUS (CE-EUS). A 54-year-old man with nonsteroidal anti-inflammatory drug intake and history of chronic alcohol pancreatitis was admitted for tarry stools. A cause for bleeding could not be identified by gastroscopy, ileocolonoscopy, abdominal ultrasound, and computed tomography [Figure 1]. However, the gastrointestinal bleeding continued. Small bowel video capsule endoscopy was performed and showed traces of blood in the duodenum. Repeated duodenoscopy presented a slight hemobilia from the papilla [Figure 2]. Therefore, hemosuccus pancreaticus was assumed, and CE-EUS indeed detected an arterial fistula to the pancreatic duct [Figure 3] and [Video 1]]. In the following, angiography showed a small pseudoaneurysm of the splenic artery [Figure 4], which was successfully treated by angiographic coiling [Figure 5] according to common guidelines.[3] Bleeding stopped after transfusion of summed up 9 units of blood. In some cases, EUS combined with Doppler ultrasound might be sufficient for the detection of the fistula[4] but failed in this patient. The useful application of CE-EUS in hemosuccus pancreaticus was previously shown in only one case report, in which the feeding vessel of a large pseudoaneurysm (42 mm) could not have been detected by angiography.[5] In conclusion, CE-EUS might be useful to detect hemosuccus pancreaticus due to small arterial pseudoaneurysms in patients with occult gastrointestinal bleeding.
Figure 1: Computed tomography of the abdomen showing chronic pancreatitis with calcifications but cannot identify the source of gastrointestinal bleeding

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Figure 2: Slight hemobilia from the papilla is shown in repeated duodenoscopy

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Figure 3: Selected image from Video 1 showing the fistula from the arterial pseudoaneurysm to the pancreatic duct

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Figure 4: Selective angiography showing a small pseudoaneurysm (<20 mm) of the splenic artery. Fistula from the pseudoaneurysm to the pancreatic duct is not demonstrated

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Figure 5: Successfully treated pseudoaneurysm of the splenic artery by angiographic coiling. Direct application of the coils into the pseudoaneurysm had to be avoided

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  Brief Description Top


CE-EUS was helpful to detect hemosuccus pancreaticus due to a small arterial pseudoaneurysm of the splenic artery in a patient with chronic pancreatitis and on-going occult gastrointestinal bleeding. Hemosuccus pancreaticus was successfully treated by angiographic coiling.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sandblom P. Gastrointestinal hemorrhage through the pancreatic duct. Ann Surg 1970;171:61-6.  Back to cited text no. 1
    
2.
Ru N, Zou WB, Qian YY, et al. A systematic review of the etiology, diagnosis, and treatment of hemosuccus pancreaticus. Pancreas 2019;48:e47-9.  Back to cited text no. 2
    
3.
Kitano M, Gress TM, Garg PK, et al. International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club. Pancreatology 2020;20:1045-55.  Back to cited text no. 3
    
4.
Pham K, Pedersen G, Halvorsen H, et al. A rare cause of hemosuccus pancreaticus diagnosed with endoscopic ultrasound. Endosc Ultrasound 2014;3:S17-8.  Back to cited text no. 4
    
5.
Yamamoto K, Itoi T, Tsuchiya T, et al. Hemosuccus pancreaticus diagnosed by contrast-enhanced endoscopic ultrasonography (with video). J Hepatobiliary Pancreat Sci 2014;21:356-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

 
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