Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper gastrointestinal bleeding

Background: Hemosuccus pancreaticus, a rare form of upper gastrointestinal bleeding, may complicate chronic pancreatitis and pose a significant diagno stic and therapeutic dilemma. Aim: To present our experience with this pote ntially lift-threatening complication of chronic pancreatitis. Methods: We reviewed our experience with management (both operative as well as angiogra phic embolization) of patients with hemosuccus pancreaticus complicating hi stologically documented chronic pancreatitis between 1976 and 1997. Diagnos is of hemosuccus pancreaticus was based on clinical presentation, preoperat ive endoscopic and radiographic imaging, operative findings, and pathologic evaluation. Results: During the period, we managed eight patients with hem osuccus pancreaticus (1.5% of all patients with chronic pancreatitis treate d surgically). Gastrointestinal bleeding presented as hematemesis in three and hematochezia in three, but all had recent melena and were anemic; three of these patients were hemodynamically unstable. Abdominal pain was presen t in six. When performed, angiography (n=6) was diagnostic of a pseudoaneur ysm; computed tomography (n=7) showed a pseudoaneurysm in two and a pseudoc yst in Five. Endoscopy (n=8) revealed blood issuing from the ampullary papi lla in two patients. Operative management (n=6) involved distal pancreatect omy, pancreatoduodenectomy, or total pancreatectomy in two patients each. A ngiographic embolization was successful in one patient, but the other died From uncontrollable hemorrhage. Conclusions: Hemosuccus pancreaticus is rar e, but should be considered in patients with chronic pancreatitis and gastr ointestinal bleeding. In the absence of pancreatitis-related indications fo r surgery, angiographic embolization can be definitive treatment. If there are pancreatitis-related indications for operation, angiographic embolizati on may allow an elective operative procedure based on structural changes of the pancreas. If embolization rails, pancreatic resection is usually requi red, often on an emergent basis.