Case Presentation: Hemosuccus pancreaticus, a rare cause of gastrointestinal (GI) bleeding, is defined as bleeding through the pancreatic duct into the ampulla of Vater. Bleeding usually occurs due to a ruptured pseudoaneurysm, and can be fatal, as it can be easily missed. Here we discuss a case that was discovered in time for appropriate intervention. A 68-year-old female was admitted to the intermediate care unit with severe abdominal pain. Her past medical history was significant for chronic pancreatitis, atrial fibrillation (Afib) and alcohol abuse. A CT scan done on admission was indicative of acute on chronic pancreatitis and a complex pancreatic cyst. She was managed as appropriate with fluid resuscitation, pain control, and early feeding, resulting in remarkable clinical improvement. On day 3 of admission, her abdominal pain began to acutely worsen with worsening hemodynamics and new-onset melena. Repeat labs were indicative of a significant drop in hemoglobin. An esophagogastroduodenoscopy was done revealing a bleed from the ampulla of Vater. A repeat CT showed a complex hemorrhagic pancreatic cyst.Interventional radiology was contacted, and an angiography was done showing pancreaticoduodenal and splenic artery bleed. These were embolized leading to the cessation of bleeding, and clinical and hemodynamic stability.
Discussion: Hemosuccus Pancreaticus is the least frequent cause of upper GI bleeding, with a reported incidence of 1/1500 among upper GI bleeds. Due to its rarity, it can be very challenging to diagnose, and thus can be fatal, with mortality rates reported to be close to 90%. Among several reported cases, it appears there is a delay in diagnosis due to difficulty visualizing the bleed on the first EGD. It is essential, therefore, to maintain a high index of suspicion for this rare condition to potentially prevent a fatal outcome.
Conclusions: In the case of an obscure gastrointestinal bleed, bleeding into the pancreatic duct must be considered as an important, likely treatable differential.