Haemosuccus pancreaticus is defined as upper gastrointestinal tract hemorrhage from the ampulla of Vater via the pancreatic duct. The term haemosuccus pancreaticus was coined by Sandblom in 1970 [1]. The most common etiology is a pseudoaneurysm of the peripancreatic arteries due to acute or chronic pancreatitis [2, 3]. It could arise from splenic (60–65%), common hepatic, gastroduodenal, or pancreaticoduodenal artery [4]. HP could be due to rupture of a pseudoaneurysm or an aneurysm of the peripancreatic artery into the duct or may be due to bleeding of the intact or aneurysm-containing artery to the pseudocyst communicating with the duct. Pseudoaneurysm formation is most commonly secondary to chronic pancreatitis and occurs in 10% of this population [4]. Chronic local inflammation is thought to lead to an increased local release of elastase, with either autodigestion of peripancreatic vessels or erosion of a concomitant pseudocyst into the artery [5]. Other rare causes of HP are peripancreatic tumor hemorrhage, congenital abnormality, trauma, and iatrogenic (endoscopic ultrasound-guided fine-needle aspiration cytology) [6]. HP mainly presents with upper gastrointestinal bleeding and colic pain. The bleeding is usually intermittent and repetitive. However, some acute cases manifested as severe hematemesis or shock and needed immediate blood transfusions [7]. The characteristic colic pain results from the increased intraductal pressure caused by obstruction of the Wirsung duct due to clot formation.
In HP, endoscopy can detect blood in the duodenum or active bleeding via the papilla in only 30% of patients [8, 9]. It is difficult to diagnose on endoscopy due to intermittent hemorrhage in most cases and its anatomical location [10, 11]. A review of literature, in patients with intermittent bleeding in nature, the source of bleeding may not be identifiable. Even though endoscopy may be normal in HP, it helps rule out other causes of upper gastrointestinal bleeding (peptic ulcers, erosive gastritis, and varices) [9, 12].
Ultrasound with Doppler could be used to find pseudocysts or aneurysms of the peripancreatic artery. The classical yin-yang flow appearance with a “to-and-fro” waveform can be appreciated within the pseudoaneurysm on Color Doppler.
CECT is an excellent modality for demonstrating pancreatic pathology and demonstrating features of chronic pancreatitis and its complications. It may show the culprit pseudoaneurysm or pseudocyst, possibly demonstrating active bleeding, along with hyperdense material (i.e., fresh blood, clots) in the pancreatic ducts. The characteristic finding of clotted blood in the pancreatic duct, known as the sentinel clot, is seldom seen on multiphase CECT [13].
Ultimately, angiography remains the gold standard for diagnosis and therapy. Angiography identifies the causative artery and allows for delineation of the arterial anatomy and therapeutic intervention [9, 14]. HP is diagnosed on clinical, endoscopic, and radiological findings, and a definitive diagnosis can be established with angiography.
Interventional radiological procedures and surgery are the primary treatment modalities. If the patient is hemodynamically stable, interventional procedures (coil or glue embolization) are effective as an initial treatment in 67–100% of cases [15]. Chandra Mohan et al. have mentioned a high overall success rate of 75–100% [13]. However, embolization of the splenic artery using coils, gelfoam, or glue may lead to splenic infarction, abscess, or septic complications. In cases where extensive collateral blood supply is present, a “sandwich” coil embolization method is preferred to prevent continued retrograde flow to the pseudoaneurysm. In contrast, a pseudoaneurysm in an expendable end artery may be treated by coil embolization of the afferent vessels alone [16]. Benz et al. had used an uncovered metal stent to treat HP, in which the stent was placed across the aneurysmic segment of the splenic artery [17]. This report suggests that implanting a metal stent may be an effective treatment for HP with low complication rates.
For hemodynamically unstable patients, emergency operations (surgical debridement and ligation) are inevitable. Most surgical series have documented a success rate of 70% to 85%, with mortality rates of 20–25% and rebleeding rates of 0–5% [18, 19].