Radiology Case Presentation Hem Bhardwaj October 15, 2004 Radiology, Period 4
HPI: 54yo male presents with hematemesis and melena x 3 days. PMH: h/o alcohol abuse Chronic pancreatitis Chronic back pain Social History: Alcohol- 1 pint/day x 20yrs; Tobacco- 2ppd x 25yrs PE: Afebrile; At OSH – midleft epigastric abdominal pain radiating to his back; @ UVA, on admission - PE WNL, benign abdominal exam; day after admission (s/p EGD)- severe (10/10) epigastric pain radiating to back Labs on admission: LFTS WNL; amylase-51, lipase-51 CBC: 9.2 7 239 27.5
Differential Diagnosis-Upper GI Bleed (UGIB): Includes: • Esophagitis/Gastritis • Esophageal varices • Mallory-Weiss tear • Peptic Ulcer Disease • Esophageal cancer • AVM +… First Diagnostic test of choice to evaluate an UGIB EGD This patient’s EGD was negative, so an abdominal CT was done……..
Hemosuccus PancreaticusACR Code 77.89 (pancreas.other) • Also known as Wirsungorrhaghia (=bleeding into the pancreatic duct) or pseudohemobilia • A very rare cause of UGIB (remember this when you get pimped on rounds) • First described in early 1930s, term coined in 1970 by Sandblom • Caused by: 1) erosion of a peripancreatic artery (branches of the celiac trunk) by a pancreatic pseudocyst or 2) caused by the formation of a peripancreatic artery aneurysm with secondary fistula formation with the pancreatic duct. • Splenic and gastroduodenal arteries most commonly affected. In this case, the patient had a pseudoaneurysm of the left gastric artery and erosion into the pancreatic duct which lead to the patient’s UGIB. • Most common cause is chronic pancreatitis. Local inflammation induces pseudoaneurysm formation.
Hemosuccus Pancreaticus (cont’d) • Diagnostic tests include: -EGD (difficult to see hemosuccus pancreaticus) -ERCP -Abdominal CT -Angiography • Radiologically, if a pseudoaneurysm distorting the pancreatic border is observed (most likely by CT) and if this occurs in the context of a patient with chronic pancreatitis with an UGIB consider hemosuccus pancreaticus. • Management includes angiographic embolization and possibly surgery if embolization fails or there are other pancreas-related indications for surgery (ex. suspicion of malignancy)
Pt W.W.--Successful left gastric pseudoaneursym embolization with microcoils.
References: Raman L et al. Pseudoaneurysm of the Superior Pancreaticoduodenal Artery, a rare cause of Hemosuccus pancreaticus. Report of a case. Surgery Today. 34(2):181-184, 2004. Koizumi J et al. Hemosuccus pancreaticus: diagnosis with CT and MRI and treatment with transcatheter embolization. Abdominal Imaging. 27:77-81, 2002. Sarkorafas GH et al. Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper GI bleeding. Langenbecks Archives of Surgery. 385(2):124-128, March 2000.