Recurrent hemosuccus pancreaticus treated by endovascular intervention alone: A rare case report

Tarachand Kamble; Ayan Husain; Akshay Dafal

doi:10.4103/jdmimsu.jdmimsu_185_19

CASE REPORT

Year : 2019 | Volume : 14 | Issue : 4 | Page : 414-416

Recurrent hemosuccus pancreaticus treated by endovascular intervention alone: A rare case report

Tarachand Kamble, Ayan Husain, Akshay Dafal
Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission	20-Nov-2019
Date of Decision	30-Nov-2019
Date of Acceptance	15-Dec-2019
Date of Web Publication	16-Jul-2020

Correspondence Address:
Dr. Ayan Husain
Room S14, Yashoda Boys Hostel, Jawaharlal Nehru Medical College, Sawangi, Wardha - 442 001, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_185_19

Abstract

Hemosuccus pancreaticus is a complication of chronic pancreatitis due to the formation of pseudoaneurysms and resultant bleeding from these aneurysms into the pancreatic duct. There are few case reports in various medical and surgical journals on recurrent hemosuccus pancreaticus being treated initially by endovascular treatment followed by the surgery. Here, we report the case of a 37-year-old male who presented with recurrent hemosuccus pancreaticus and was successfully treated with endovascular intervention alone. This report highlights that such patients should be managed with endovascular intervention apart from the surgery.

Keywords: Coil embolization, pancreatitis, pseudoaneurysm

How to cite this article:
Kamble T, Husain A, Dafal A. Recurrent hemosuccus pancreaticus treated by endovascular intervention alone: A rare case report. J Datta Meghe Inst Med Sci Univ 2019;14:414-6

How to cite this URL:
Kamble T, Husain A, Dafal A. Recurrent hemosuccus pancreaticus treated by endovascular intervention alone: A rare case report. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2021 Jan 27];14:414-6. Available from: http://www.journaldmims.com/text.asp?2019/14/4/414/289847

Introduction

In chronic pancreatitis, pseudoaneurysm formation is by enzymatic digestion and destruction of vessel wall, leading to bleeding into the pancreatic duct which manifests as intermittent hemetemesis, malena, and a drop in hematocrit values. This is known as hemosuccus pancreaticus or hemobilia.^[1],[2] The treatment includes surgery and endovascular procedures such as coil embolization and balloon occlusion. Moreover, the treatment of recurrent hemosuccus pancreaticus is the surgery.^[3] However, on review of the literature, not a single case report could be found where endovascular intervention alone was done as definitive treatment in recurrent hemosuccus pancreaticus. Hence, we report this case.

Case Report

A 37-year-old male presented to the department of medicine with abdominal pain of 2 days duration and three episodes of hemetemesis. There was no history of constipation, abdominal distension, rash, diarrhea, urinary complaints, or fever. There was no history of diabetes mellitus, hypertension, or tuberculosis. He was a known case of chronic pancreatitis due to chronic alcohol use. He was admitted with similar complaints 1 year ago. On examination, the patient was conscious but in agony. Pulse rate was 116/min, and blood pressure was 110/60 mm of Hg. On abdominal examination, tenderness was present in the epigastric region without any peritoneal signs. On laboratory investigations, hemoglobin was 10 g%; total leukocyte count was 10,300/dl platelet count was 1.4 Lacs/dl. Liver function tests revealed aspartate aminotransferase values of 350 IU/L and alanine aminotransferase was 450 IU/L. Prothrombin time and international normalized ratio were within the normal range. Blood urea and creatinine were normal. HIV and Hepatitis B and C screening were negative. Serum amylase was 1404 IU/L, and lipase was 2132 IU/L. Ultrasonography of the abdomen revealed bulky pancreas and fatty liver disease without any portal hypertension. Upper gastrointestinal (GI) endoscopy was normal with no evidence of any varices. His previous abdominal computed tomography (CT) angiography had showed pseudoaneurysm of the gastroduodenal artery and was managed conservatively at that time due to financial constraints. This time abdominal CT angiography showed pseudoaneurysm of the superior branch of the pancreaticoduodenal artery and gastroduodenal artery [Figure 1]. He was treated with intravenous fluids, proton-pump inhibitor infusion, and opioid analgesics. Surgery and interventional radiology consultations were obtained. He was not fit for the surgery as liver functions and amylase and lipase were deranged. A trial of endovascular coil embolization of the involved artery was planned. He successfully underwent endovascular coil embolization of the gastroduodenal artery [Figure 2]. His symptoms resolved postprocedure, and his serum and amylase lipase both returned to normal values over the next 2 days. On follow-up after 12 months, he was doing well.

Figure 1: Abdominal computed tomography angiography image showing pseudoaneurysm of the superior branch of the pancreaticoduodenal artery and gastroduodenal artery

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Figure 2: Computed tomography of the abdomen image showing hemorrhagic pseudocyst of pancreas in the head region which was then successfully treated with endovascular coil embolization of the gastroduodenal artery

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Discussion

Hemosuccus pancreaticus commonly involves the splenic, common hepatic, gastroduodenal, and pancreaticoduodenal arteries. Colicky epigastric pain followed by malena or hemetemesis over the next 30 min to 48 h is the usual presentation.^[1],[2] The colicky pain is the result of obstruction of the Wirsung duct by clot causing increased intraductal pressure.^[4] Upper GI endoscopy is often normal as it cannot detect bleeding from the papilla of Vater. CT angiography is the gold standard for the diagnosis, particularly in hemodynamically stable patients.^[5] The treatment includes surgery and endovascular procedures such as coil embolization, balloon occlusion, and stent grafting.^[6] Reports have shown 75%–100% success, morbidity 14%–25%, and mortality 0%–30% associated with endovascular procedures. About 3% patients require repeat endovascular treatment due to rebleed. Endovascular procedures are also associated with a lower risk of cellulitis at the site of femoral access and septic complications compared to the surgery. Surgery is performed when the endovascular treatment is either unavailable or if it fails. Moreover, surgery may not be the choice of treatment in cases involving different arteries due to high risk of surgical morbidities.^{[7],[8],[9],[10],[11],[12],[13],[14],[15],[16]} Endovascular treatment is a feasible and effective treatment in cases involving different arteries, especially in the setting of acute on chronic pancreatitis.^[6],[7] In review of the literature, we could not find a case report of acute on chronic pancreatitis with recurrent hemosuccus pancreaticus involving different arteries treated with endovascular intervention.

The purpose of this case report is to highlight this uncommon, yet catastrophic manifestation of recurrent hemosuccus pancreaticus involving different arteries which can be managed by endovascular intervention, and surgery may not be necessary in these cases. Further studies are needed to formulate the standard treatment protocol for recurrent hemosuccus pancreaticus involving different arteries.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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