A 34 year old African American male with history of alcoholism, chronic pancreatitis, recurrent upper GI bleeding with unknown etiology presented with acute onset of epigastric and LUQ abdominal pain, hematemesis and melena. On presentation the heart rate was 98 and BP was 98/54. Physical exam revealed tenderness and guarding in the epigastric region. Cardiac and respiratory examinations were unremarkable. Lab results showed elevated Lipase (1129) and a drop in hemoglobin from baseline of 11 to 8.6 gms. He had a similar episode 4 weeks ago to another hospital with upper GI bleed and hemoglobin of 4.3 gms. Esophagogastroduodenoscopy (EGD) failed to reveal the source of bleeding so he was stabilized with blood transfusions and sent home. CT scan on this admission demonstrated calcifications of the pancreatic head & uncinate process and findings suggestive of acute on chronic pancreatitis. Immediate EGD with a side viewing scope showed active bleeding from the ampulla of Vater. An angiogram was done, Celiac, splenic and superior pancreatic arteries were visualized. Pseudo-aneurysm of superior pancreatic artery was detected and was successfully embolized. Bleeding immediately ceased and no blood transfusion was needed. Symptoms improved gradually over the next few days, the patient was followed up to one year with no recurrence reported.
Hemobilia, defined as bleeding from the hepatobiliary tract, is a rare cause of gastrointestinal bleeding. Clinically it is evident as blood oozing from ampulla of Vater during EGD or ERCP. Hemosuccus pancreaticus (HP) is a rare cause of hemobilia, it results when an artery in the vicinity of pancreas develops pseudo-aneurysm with subsequent rupture and bleeding into the pancreas. Although rare, HP has been reported in literature. While most reported cases highlighted splenic artery bleeding, bleeding from the superior pancreatic artery was less reported. Regardless the source, the clinical presentation is similar and is usually a combined acute pancreatitis and upper GI bleeding. Many of the cases reported showed some correlation with chronic alcoholism and chronic pancreatitis. Reported incidence of the disease is 1/1500 among all upper GI bleeds. The disease is fatal if not diagnosed and treated properly. Using a side viewing EGD facilitates the visualization of the ampulla. The diagnosis can be confirmed by angiogram which can be followed by arterial embolization; this might require transferring the patient to a tertiary care center. Surgery should be reserved as an alternative option if the initial approach fails.
HP should be considered in all patients with chronic alcoholic pancreatitis with upper GI bleed when EGD fails to reveal other possible causes of the bleeding. Once suspected by clinical picture and EGD findings, Angiogram is the best method to detect the source of bleeding. Hospitalists are the first physician to encounter those cases, but the availability of interventional radiology and / or specialist GI surgery is required for proper management which might need patient transfer to a tertiary care facility.