Pancreaticoduodenal Artery and Superior Mesenteric Artery Pseudoaneurysm Associated With Hemosuccus Pancreaticus

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A 24-year-old man who underwent a second partial gastrectomy was admitted to our hospital with gastrointestinal (GI) bleeding. In autumn 2005, he had several episodes of GI bleeding after epigastric intermittent pain. There were 1 or 2 attacks every year. Three years later, he suddenly vomited about 1000 mL blood on a bus and was sent to a hospital; his hemoglobin had dropped to 40 g/L. One month later, he underwent first partial gastrectomy for duodenal bulb ulcer associated with active bleeding. Then the second gastrectomy was performed for 2 episodes of anastomotic ulcer bleeding in December 2008. On February 4, 2009, he had hematemesis again. Computed tomography (CT) scanning showed splenomegaly and signs of portal hypertension, and magnetic resonance cholangiopancreatography (MRCP) image revealed normal biliary tract and pancreas. On March 9, he was admitted to our hospital; the serum gastrin and amylase levels were normal. MRCP image showed normal common bile duct. CT scanning revealed a slightly distended pancreatic tube and a normal size pancreas.

The upper GI hemorrhage occurred twice, with volume of 1000–1200 mL, after arriving at our hospital. On March 20, 2009, a routine B ultrasound scanning revealed an expanded bile duct. Then enhanced CT scanning showed a round, evenly enhanced mass (Figure A) in the accreted pancreatic head, measuring 3.5 × 3.0 cm. The pancreatic duct and common bile duct were obviously expanded. Artery imaging showed an artificial aneurysm linked to both branches of superior mesenteric artery and pancreaticoduodenal artery (Figure B). The patient was diagnosed as having pseudoaneurysm and underwent pancreaticoduodenectomy. The pseudoaneurysm was in pancreatic duct (Figure C), measuring 2.5 × 2.5 cm, and pathologic analysis confirmed retention cyst associated with bleeding. The patient recovered uneventfully and has been well, without recurrent bleeding, for 4 months since the surgery.

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Hemosuccus pancreaticus (HP), defined as bleeding through the pancreatic duct, is a rare cause of GI bleeding, usually as a result of rupture of pseudoaneurysm, which is usually associated with pancreatitis, abdominal surgery, and trauma. Causes of upper GI bleeding in patients with pancreatitis are multiple; however, as many as 10% of patients develop peripancreatic artery pseudoaneurysm. Commonly involved arteries are the splenic, gastroduodenal, and pancreaticoduodenal artery.¹ The swelling of pseudoaneurysm made the pancreatic ducts expand; rupture and bleeding of the pseudoaneurysm resulted in abdominal pain and GI hemorrhage. We report on a patient with HP.

His diagnosis of HP was very difficult. He was diagnosed wrongly as having, in order, duodenal ulcer, anastomosis ulcer, portal hypertension, and gastrinoma, and he underwent 3 operations. This case showed different manifestations from the previous reports; this was the reason that correct diagnosis was not made as soon as possible.¹, ², ³ First, his symptoms were not like those of other pseudoaneurysms, without symptom of fever, jaundice, and history of pancreatitis, abdominal surgery, and trauma.², ³ Second, the pseudoaneurysm lasted for a very short time and could break and bleed before long, so 3 rounds of CT scanning and 2 rounds of MRCP imaging did not find the lesion, whereas others presented early and lasted for long time.⁴ These untypical, flexible clinical symptoms increased the difficulty of the diagnosis.³, ⁴ Third, the lesion was in the main pancreatic duct, and the pancreatic tissue was almost normal. When it ruptured, the blood entered into the duodenum through duodenal nipple without jaundice. However, others had pancreatic tissue necrosis or destroyed, which became a diagnostic clue.³, ⁴ Fourth, according to the artery imaging, both small branches of pancreaticoduodenal artery and superior mesenteric artery provided the blood supply to pseudoaneurysm (Figure B), which was very rare and different from other patients.¹, ², ³, ⁴

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References 

1. Kapoor S, Rao P, Pal S, et al. Hemosuccus pancreaticus: an uncommon cause of gastrointestinal hemorrhage—a case report. J Pancreas. 2004;5:373–376(online)
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2. Fujii Y, Shimada H, Endo I, et al. Management of massive arterial hemorrhage after pancreatobiliary surgery: does embolotherapy contribute to successful outcome?. J Gastrointest Surg. 2007;11:432–438
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3. Massani M, Bridda A, Caratozzolo E, et al. Hemosuccus pancreaticus due to primary splenic artery aneurysm: a diagnostic and therapeutic challenge. J Pancreas. 2009;10:48–52
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4. Bohl JL, Dossett LA, Grau AM. Gastroduodenal artery pseudoaneurysm associated with hemosuccus pancreaticus and obstructive jaundice. J Gastrointest Surg. 2007;11:1752–1754
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