Hemosuccus pancreaticus, a diagnostic challenge

Hemorrhage from the papilla of Vater via the pancreatic duct, known as Hemosuccus pancreaticus (HP), is an uncommon cause of intermittent upper gastrointestinal bleeding. Up till now, less than 100 cases are reported in the literature (1). HP cannot be easily detected by endoscopy. The diagnosis is supported by direct visualization of the hemorrhage through the main pancreatic duct at angiography. We report an unusual case of HP. A 30-year-old male with a history of chronic pancreatitis secondary to alcohol abuse presented to the emergency room with epigastric pain, hematemesis and melenic stools. He had two prior admissions for similar episodes and emergent endoscopy each time revealed fresh blood in the second part of the duodenum and in the anterior wall of the stomach. During one of these episodes, a small non-bleeding angiodysplasia in the stomach was treated with argon plasma coagulation. A CT scan of the abdomen without IV contrast at prior hospitalization showed an atrophic pancreas with extensive calcification but was otherwise unremarkable. On this admission he was hypotensive with a hemoglobin of 5.9 g/dL (13.8-17.2 g/dL). After initial resuscitation, an esophagogastroduodenoscopy revealed fresh blood in the second part of the duodenum at the site of the major papilla as shown in Figure 1. Examination with a sideviewing endoscope revealed blood oozing from both minor and major papilla. An endoscopic retrograde cholangiopancreatography with a spy scope exam showed the presence of blood in the pancreatic duct and normal biliary system. Emergent selective celiac arteriogram revealed active contrast extravasation from the superior pancreaticoduodenal branch of the gastroduodenal artery. Coil embolization of the artery was then carried out at and before the level of the acute bleed with satisfactory result. The patient remains asymptomatic with no further evidence of bleeding on regular follow up for 6 months.