From the Guidelines
Hemosuccus pancreaticus should be treated with selective angiographic embolization of the bleeding vessel as the first line of treatment, given its high success rates of 79-100% and lower morbidity compared to surgery, as supported by the most recent evidence 1.
Diagnosis
Hemosuccus pancreaticus is a rare cause of gastrointestinal bleeding characterized by bleeding from the pancreatic duct into the duodenum through the ampulla of Vater. It typically presents with intermittent upper gastrointestinal bleeding and abdominal pain. The most common cause is a pseudoaneurysm of the splenic artery associated with chronic pancreatitis, though it can also result from pancreatic tumors, vascular malformations, or trauma. Diagnosis requires a high index of suspicion and often involves CT angiography, which can identify the source of bleeding 1.
Treatment
Initial management includes hemodynamic stabilization with IV fluids and blood transfusions as needed. Definitive treatment typically involves interventional radiology with selective angiographic embolization of the bleeding vessel. This approach has been shown to have high success rates, with an 88% to 100% success rate of visceral arteriography for diagnosis of endoscopically refractory bleeding from the esophagus due to inflammatory or neoplastic pathology 1. Surgical options, including distal pancreatectomy or ligation of the bleeding vessel, are reserved for cases where embolization fails or isn't available.
Management and Follow-up
Patients should be monitored closely after treatment as rebleeding can occur, particularly in those with ongoing pancreatitis. Early diagnosis and prompt intervention are crucial for reducing mortality in this condition. The use of CT angiography and selective angiographic embolization has improved outcomes in patients with hemosuccus pancreaticus, highlighting the importance of a multidisciplinary approach to management 1.
Key Points
- Hemosuccus pancreaticus is a rare cause of gastrointestinal bleeding that requires a high index of suspicion for diagnosis.
- CT angiography is a key diagnostic tool for identifying the source of bleeding.
- Selective angiographic embolization is the preferred treatment for hemosuccus pancreaticus, with high success rates and lower morbidity compared to surgery.
- Patients should be closely monitored after treatment for signs of rebleeding, particularly those with ongoing pancreatitis.
From the Research
Diagnosis of Hemosuccus Pancreaticus
- Hemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding that often presents significant diagnostic and therapeutic challenges 2, 3, 4.
- Diagnosis of hemosuccus pancreaticus can be based on clinical presentation, preoperative endoscopic and radiographic imaging, operative findings, and pathologic evaluation 3.
- Endoscopic diagnosis is possible in 64.4% of patients, and angiogram localization of bleeding source is noted in 94.2% of patients 5.
- Contrast-enhanced CT angiography with reconstruction of the arteries can be performed regardless of whether the patient shows signs of active bleeding or not to aid in diagnosis 6.
Treatment of Hemosuccus Pancreaticus
- All hemodynamically stable patients with hemosuccus pancreaticus should undergo prompt initial angiographic evaluation, and if possible, embolization 2.
- Hemodynamically unstable patients and those following unsuccessful embolization should undergo emergency haemostatic surgery 2.
- Angiographic embolization can be definitive treatment in the absence of pancreatitis-related indications for surgery 3.
- Conventional angioembolization has a success rate of 95.9% and is the most preferred first-line therapeutic approach in majority of cases 5.
- Surgery may be required in cases where embolization fails, often on an emergent basis 3, 5.