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Walensi M, Albers D, Dakkak D, Meng W, Heesen R, Nassenstein K, Piotrowski M, Krasniuk I, Tsilimparis N, Drongitis P, Hoffmann JN. Hemosuccus pancreaticus - Multidisciplinary therapy for a splenic artery aneurysm, ruptured into the pancreatic duct. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1708-1714. [PMID: 39227007 DOI: 10.1055/a-2364-4462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
BACKGROUND Numerous conditions may lead to gastrointestinal bleeding (GIB). Compared with common causes, hemosuccus pancreaticus (HP) is a scarce and potentially life-threatening condition. CASE PRESENTATION We report the case of a 45-year-old female patient who suffered from hematemesis and subsequent hemorrhagic shock. In repeat esophagogastroduodenoscopies, bleeding from the major duodenal papilla was detected. To stop the acute bleeding, an ERCP was performed, and a plastic stent was inserted into the pancreatic duct (PD). Subsequently, MR and CT scans demonstrated a pseudoaneurysm of the splenic artery (SA) with a fistula to the PD. An interventional therapy approach failed due to a highly twisted course of the SA. Thus, the patient underwent surgery with ligation of the SA. The stent from the PD was removed postoperatively, and the patient recovered well. A histological examination of the SA revealed fibromuscular dysplasia. A lifelong ASA therapy was prescribed, and the patient was discharged on the 14th postoperative day in good condition. CONCLUSION The diagnosis and treatment of HP might be impeded due to its multiple causes, ambiguous symptoms, and challenging diagnostic verification. Being a potentially life-threatening condition, the knowledge of this rare entity and the provision of multidisciplinary and multimodal therapy are mandatory for the successful treatment of patients with obscure GIB and proven HP.
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Affiliation(s)
- Mikolaj Walensi
- Department of Vascular Surgery and Phlebology, CONTILIA Group - Heart and Vascular Center, Essen, Germany
| | - David Albers
- Abteilung für Innere Medizin und Gastroenterologie, Elisabeth-Krankenhaus Essen Klinik fur Innere Medizin und Gastroenterologie, Essen, Germany
| | - Dani Dakkak
- Klinik für Innere Medizin und Gastroenterologie, Elisabeth-Krankenhaus Essen Klinik fur Innere Medizin und Gastroenterologie, Essen, Germany
| | - Wei Meng
- Department of Vascular Surgery, Klinikum Oberberg GmbH, Gummersbach, Germany
| | - Roland Heesen
- Department of Angiology, Contilia Group - Heart and Vascular Center, Essen, Germany
| | - Kai Nassenstein
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michal Piotrowski
- Department of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Iuri Krasniuk
- Department of Surgery, Städtisches Klinikum Solingen, Solingen, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
| | - Pavlos Drongitis
- Department of Vascular Surgery and Phlebology, CONTILIA Group - Heart and Vascular Center, Essen, Germany
| | - Johannes N Hoffmann
- Department of Vascular Surgery and Phlebology, CONTILIA Group - Heart and Vascular Center, Essen, Germany
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Chooklin S, Chuklin S, Posivnych M, Krystopchuk S. Hemosuccus pancreaticus as a rare cause of gastrointestinal bleeding. EMERGENCY MEDICINE 2023; 19:58-69. [DOI: 10.22141/2224-0586.19.2.2023.1559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Hemosuccus pancreaticus is a life-threatening condition that should be considered in patients with abdominal pain, gastrointestinal hemorrhage and high serum amylase. The varied presentation of hemosuccus pancreaticus and the limited literature evidence due to its rarity make it challenging to diagnose. Diagnostic modalities include contrast-enhanced computed tomography scans, endoscopic procedures (esophagoduodenoscopy and endoscopic retrograde cholangiopancreatography) and angiography. Therapeutic management through an interventional radiology using coil embolization is safe and effective in hemodynamically stable patients with hemosuccus pancreaticus. Endosonography can be an innovative approach for the diagnosis and treatment of patients in whom contrast cannot be administered; however, its safety and efficacy need to be confirmed by future studies. This review presents current views on the diagnosis and treatment of patients with hemosuccus pancreaticus.
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Moon SM, Paik KH, Kim JC, Park WS. A case report on the role of endoscopic retrograde cholangiopancreatography in the diagnosis of hemosuccus pancreaticus. Medicine (Baltimore) 2022; 101:e31561. [PMID: 36397353 PMCID: PMC9666211 DOI: 10.1097/md.0000000000031561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding that sometimes leads to life-threatening conditions. However, the diagnosis of HP is often delayed due to its rarity and intermittent signs of bleeding, making it challenging to determine the source of bleeding in some patients. PATIENT CONCERNS An 83-years-old man was transferred to our hospital for evaluation of the source of intermittent upper gastrointestinal bleeding involving melena and worsening anemia. DIAGNOSIS HP was diagnosed via endoscopic retrograde cholangiopancreatography (ERCP) and sequential angiography using a multidisciplinary approach. INTERVENTIONS Initial upper and lower gastrointestinal endoscopies did not reveal any source of bleeding. Emergency upper endoscopy performed when the patient had hematochezia and hypotension confirmed a spurt of bleeding from the major duodenal papilla. However, contrast-enhanced computed tomography and angiography could not identify the source of the bleeding from the major duodenal papilla. ERCP for inducing bleeding from the source and indicating the bleeding point was performed according to the decision of the multidisciplinary team. Immediately thereafter, sequential angiography was performed and HP, due to the rupture of a pseudoaneurysm of the splenic artery, was diagnosed. As a result, surgical resection of the pancreas could be avoided by accurately embolizing the bleeding focus of HP using a multidisciplinary team approach. OUTCOMES The patient was discharged in a hemodynamically stable condition. There was no further gastrointestinal bleeding or procedure-related complication until 6 months after discharge. LESSONS HP should be considered by endoscopists during the differential diagnosis of intermittent upper gastrointestinal bleeding in patients with a history of pancreatitis. A multidisciplinary team approach is an effective method to determine the source or location of bleeding, which may reduce mortality and morbidity by avoiding additional pancreatectomies.
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Affiliation(s)
- Sung Mi Moon
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Jung-gu, Daejeon, Republic of Korea
| | - Kyu-Hyun Paik
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Jung-gu, Daejeon, Republic of Korea
| | - Ji Chang Kim
- Department of Radiology, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Jung-gu, Daejeon, Republic of Korea
| | - Won Suk Park
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Jung-gu, Daejeon, Republic of Korea
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Ackermann TG, Gao H, Croagh DG. Multimodal treatment of refractory haemorrhage from haemosuccus pancreaticus. ANZ J Surg 2021; 92:859-861. [PMID: 34355841 DOI: 10.1111/ans.17124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Travis George Ackermann
- Upper Gastrointestinal/Hepatobiliary and General Surgery Unit, Monash Health, Clayton, Victoria, Australia
| | - Hugh Gao
- Upper Gastrointestinal/Hepatobiliary and General Surgery Unit, Monash Health, Clayton, Victoria, Australia
| | - Daniel Gerald Croagh
- Upper Gastrointestinal/Hepatobiliary and General Surgery Unit, Monash Health, Clayton, Victoria, Australia.,Department of Surgery, Monash University, Clayton, Victoria, Australia
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Yashavanth HS, Jagtap N, Singh JR, Ramchandani M, Lakhtakia S, Tandan M, Gupta R, Vamsi M, Bhaware B, Rao GV, Reddy DN. Hemosuccus Pancreaticus: A systematic approach. J Gastroenterol Hepatol 2021; 36:2101-2106. [PMID: 33445212 DOI: 10.1111/jgh.15404] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/27/2020] [Accepted: 01/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Hemosuccus pancreaticus is considered as one of the rare cause of upper gastrointestinal bleeding. Intermittent nature of bleeding and lack of standardized approach for diagnosis has resulted in significant delay in definitive management. METHODS We retrospectively analyzed prospectively maintained data of patients with suspected hemosuccus pancreaticus between January 2010 and December 2019. RESULTS Out of 114 patients, 87 patients were diagnosed with hemosuccus pancreaticus. Mean age was 35.7 ± 11.7 years with 89.7% men. Median duration of bleeding before diagnosis was 10 days, with 40.2%, 10.3%, and 5.7% patients had symptoms beyond 1, 6, and 12 months, respectively. Visceral artery aneurysm was noted in 62% of cases with splenic artery aneurysm (37.9%) being the common source of bleed. Rarer causes noted were superior mesenteric artery aneurysm, pancreatic adenocarcinoma, gastrointestinal stromal tumor, and post-endoscopic retrograde cholangiopancreatography (2.3% each). Santorinirrhage was seen in 3.4% patients. Endoscopic diagnosis was possible in 64.4% of patients, and angiogram localization of bleeding source was noted in 94.2%. A 56.3% of patients underwent conventional angioembolization with 95.9% success and 28.7% underwent surgery, with overall rebleeding rate of 11.5%. CONCLUSIONS Early diagnosis of hemosuccus pancreaticus avoids prolonged suffering, multiple hospital admissions, and multiple blood transfusions. It is not uncommon in the absence of aneurysm. In cases of high suspicion, repeating the endoscopy with proper technique and proper timing increases the yield. Angioembolization remains the most preferred first line therapeutic approach in majority of cases.
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Affiliation(s)
- H S Yashavanth
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitin Jagtap
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Jagadeesh Rampal Singh
- Department of Interventional Radiology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manu Tandan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Gupta
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Vamsi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Bhushan Bhaware
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - G V Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D N Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Singhai A, Manoria P, Bose R. Hemosuccus Pancreaticus: Culprit of Life-Threatening Upper Gastrointestinal Bleeding in Acute Pancreatitis. J Emerg Trauma Shock 2021; 14:48-50. [PMID: 33911437 PMCID: PMC8054800 DOI: 10.4103/jets.jets_98_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/29/2020] [Accepted: 11/30/2020] [Indexed: 11/08/2022] Open
Abstract
Hemosuccus pancreaticus (HP), a term used for upper gastrointestinal bleeding (UGIB) from the ampulla of Vater through the pancreatic duct, is most commonly caused by the rupture of aneurysm of the splenic artery associated with acute or chronic pancreatitis. It is a rare cause of UGIB, and estimates of its rate (1/1500) are based on small case series. Because of its rarity, the diagnosis is easily overlooked. Here, we have described a case of alcohol-induced acute pancreatitis that developed hemorrhagic shock due to HP.
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Affiliation(s)
- Abhishek Singhai
- Department of Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Piyush Manoria
- Manoria Hospital and Research Centre, Bhopal, Madhya Pradesh, India
| | - Rishabh Bose
- Department of Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Cui HY, Jiang CH, Dong J, Wen Y, Chen YW. Hemosuccus pancreaticus caused by gastroduodenal artery pseudoaneurysm associated with chronic pancreatitis: A case report and review of literature. World J Clin Cases 2021; 9:236-244. [PMID: 33511191 PMCID: PMC7809673 DOI: 10.12998/wjcc.v9.i1.236] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/30/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hemosuccus pancreaticus is a very rare but severe form of upper gastrointestinal hemorrhage. The most common etiology is peripancreatic pseudoaneurysm secondary to chronic pancreatitis. Due to the rarity of gastroduodenal artery pseudoaneurysms, most of the current literature consists of case reports. Limited knowledge about the disease causes diagnostic difficulty. CASE SUMMARY A 39-year-old man with a previous history of chronic pancreatitis was hospitalized due to hematemesis and melena for 2 wk, with a new episode lasting 1 d. Two weeks prior, the patient had visited a local hospital for repeated hematemesis and melena. Esophagogastroduodenoscopy indicated hemorrhage in the descending duodenum. The patient was discharged after the bleeding stopped, but hematemesis and hematochezia recurred. Bedside esophago-gastroduodenoscopy showed no obvious bleeding lesion. On admission to our hospital, he had hematemesis, hematochezia, left middle and upper abdominal pain, severe anemia, and elevated blood amylase. After admission, intermittent hematochezia was observed. Abdominal contrast-enhanced computed tomography revealed a pseudoaneurysm in the pancreas head. Angiography confirmed the diagnosis of gastroduodenal artery pseudoaneurysm. The pseudoaneurysm was successfully embolized with a coil and cyanoacrylate. No bleeding was observed after the operation. After discharge from the hospital, a telephone follow-up showed no further bleeding signs. CONCLUSION Hemosuccus pancreaticus caused by gastroduodenal artery pseudoaneurysm associated with chronic pancreatitis is very rare. This diagnosis should be considered when upper gastrointestinal bleeding and abdominal pain are intermittent. Abdominal enhanced computed tomography and angiography are important for diagnosis and treatment.
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Affiliation(s)
- Hai-Yu Cui
- Department of Gastroenterology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - Cheng-Hang Jiang
- Department of Emergency Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - Jie Dong
- Department of Gastroenterology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - Yang Wen
- Department of Radiology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
| | - You-Wei Chen
- Department of Gastroenterology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou 310014, Zhejiang Province, China
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8
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Mandaliya R, Krevsky B, Sankineni A, Walp K, Chen O. Hemosuccus Pancreaticus: A Mysterious Cause of Gastrointestinal Bleeding. Gastroenterology Res 2014; 7:32-37. [PMID: 27785267 PMCID: PMC5051140 DOI: 10.14740/gr596w] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2014] [Indexed: 02/07/2023] Open
Abstract
Hemosuccus pancreaticus (bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater) is a rare, potentially life-threatening and obscure cause of upper gastrointestinal bleeding. It is caused by rupture of the psuedoaneurysm of a peripancreatic vessel into pancreatic duct or pancreatic psuedocyst in the context of pancreatitis or pancreatic tumors. It can pose a significant diagnostic and therapeutic dilemma due to its anatomical location and that bleeding into the duodenum is intermittent and cannot be easily diagnosed by endoscopy. A 61-year-old female with HIV and alcoholism presented with 3 weeks of intermittent abdominal pain and melena. Examination revealed hypotension with pallor and mild epigastric tenderness. She was found to have severe anemia and a high serum lipase. It was decided to perform a contrast-enhanced computed tomography (CT) scan that demonstrated a hemorrhagic pancreatic pseudocyst with possible active bleeding into the cyst. An emergent angiogram showed a large pseudoaneurysm of the pancreaticoduodenal artery that was successfully embolized. Subsequent endoscopy showed blood near ampulla of Vater confirming the diagnosis of hemosuccus pancreaticus. Thus the bleeding pseudocyst was communicating with pancreatic duct. The patient had no further episodes of gastrointestinal bleeding. Hemosuccus pancreaticus should be considered in patients with intermittent crescendo-decrescendo abdominal pain, gastrointestinal bleeding and a high serum lipase. Contrast-enhanced CT scan can be an excellent initial diagnostic modality and can lead to prompt angiography for embolization of the bleeding pseudoaneurysm and can eliminate the need for surgery.
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Affiliation(s)
- Rohan Mandaliya
- Department of Internal Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Benjamin Krevsky
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Abhinav Sankineni
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Kiley Walp
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Oliver Chen
- Department of Radiology, Temple University School of Medicine, Philadelphia, PA, USA
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9
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Han B, Song ZF, Sun B. Hemosuccus pancreaticus: a rare cause of gastrointestinal bleeding. Hepatobiliary Pancreat Dis Int 2012; 11:479-88. [PMID: 23060392 DOI: 10.1016/s1499-3872(12)60211-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hemosuccus pancreaticus (HP) is defined as upper gastrointestinal (GI) hemorrhage from the papilla of Vater via the pancreatic duct and is a rare cause of digestive bleeding. DATA SOURCE A PubMed search of relevant articles published from January 1967 to September 2011 was performed to identify current information about HP in terms of its etiology, pathophysiology, clinical presentation, diagnosis and management. RESULTS A variety of etiological factors, most commonly chronic pancreatitis but also tumors and vascular diseases, can lead to this condition. Appropriate endoscopic or radiologic procedures should be chosen to establish a precise diagnosis for patients, especially those with a known history of pancreatic disorders, who present with abdominal pain, GI hemorrhage and hyperamylasemia. There are two main therapeutic options for this condition: angiographic embolotherapy and surgery. Both treatments can stop bleeding, but angiographic embolotherapy is the treatment of choice for stable patients. Recently, new and less invasive treatments have emerged to treat this condition. CONCLUSIONS Because of its rarity and broad spectrum of causes, HP is difficult to diagnose accurately. However, appropriate endoscopic and radiologic procedures are extremely helpful for establishing a correct diagnosis. Both angiographic embolotherapy and surgery are reliable treatment options for this condition, and transcatheter intervention is the treatment of choice for clinically stable patients. Additional innovative treatments have emerged, but their effectiveness and safety must be confirmed.
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Affiliation(s)
- Bing Han
- Department of Pancreatic and Biliary Surgery, First Clinical Hospital, Harbin Medical University, Harbin 150001, China
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10
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Acute gastrointestinal bleeding: CT angiography with multi-planar reformatting. ACTA ACUST UNITED AC 2010; 36:115-25. [DOI: 10.1007/s00261-010-9615-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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11
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Mirza S, Panesar SS. Pancreatic Pseudo aneurysm: An Unusual Cause of Gastrointestinal Bleeding and it's Radiologically guided Management. A Case Report and Review of the Literature. Scott Med J 2008. [DOI: 10.1258/rsmsmj.53.1.60g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Singh A, Gueret R, Guralnick AS. HEMOSUCCUS PANCREATICUS: AN UNCOMMON CAUSE OF UPPER GASTROINTESTINAL BLEEDING. Chest 2007. [DOI: 10.1378/chest.132.4_meetingabstracts.720b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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13
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Pasha SF, Blair JE, Garvey PB, Gray RJ, Mulligan DC, Collins JM, Heigh RI. Hemosuccus Pancreaticus in the Era of Capsule Endoscopy and Double Balloon Enteroscopy Complicated by Multifocal Mycobacterium chelonae/abscessus Infection. Case Rep Gastroenterol 2007; 1:38-47. [PMID: 21487470 PMCID: PMC3073786 DOI: 10.1159/000104977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Hemosuccus pancreaticus is a rare etiology of obscure gastrointestinal bleeding characterized by bleeding into the pancreatic duct. The diagnosis may be delayed for months to years, due to the episodic nature of bleeding and failure to consider the diagnosis. Patients often undergo multiple endoscopies and radiologic evaluations prior to diagnosis. Incidental gastrointestinal findings may lead to unnecessary endoscopic and surgical interventions. This report describes a patient with hemosuccus pancreaticus diagnosed in the era of video capsule endoscopy and double balloon enteroscopy, whose management was complicated by multifocal Mycobacteria chelonae/abscessus infection.
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Affiliation(s)
- Shabana F Pasha
- Division of Gastroenterology & Hepatology, Mayo Clinic Scottsdale, Scottsdale, Ariz., USA
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14
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Abstract
Hemosuccus pancreaticus is a rare cause of gastrointestinal bleeding from the duct of Wirsung into the duodenum via the ampulla of Vater. Hemosuccus pancreaticus is difficult to diagnose because the bleeding is usually intermittent, and the clinical findings are often discordant. Patients present with pain, either left upper quadrant or epigastric, and bleeding, which may present as melena, bright red blood per rectum, or even shock, if the hemorrhage is severe. Hemosuccus pancreaticus is usually caused by rupture of a pseudoaneurysm of a peri-pancreatic artery, often the splenic artery, in the setting of pancreatitis; other causes are very rare. In this report, for the first time to our knowledge, we present a case of hemosuccus pancreaticus that occurred as a complication of bariatric surgery.
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15
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Kuzuya A, Mizuno K, Miyake H, Iyomasa S, Matsuda M. Hemosuccus pancreaticus caused by rupture of a true splenic artery aneurysm following a failure of coil embolization. Ann Vasc Surg 2006; 20:130-3. [PMID: 16374536 DOI: 10.1007/s10016-005-9100-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hemosuccus pancreaticus, particularly that caused by a primary aneurysm, is rarely encountered. Thus, its clinical characteristics are not well known. We report the case of a 53-year old man, who presented with hemosuccus pancreaticus caused by the rupture of an atherosclerotic aneurysm of the splenic artery and underwent distal pancreatectomy with splenectomy. Only 16 cases of hemosuccus pancreaticus due to primary aneurysm have previously been reported in the English-language literature between 1970 and 2003. The relevant literature was also reviewed. The review of the literature showed that because diagnosis is difficult to establish due to intermittent hemorrhage, a long time was often taken before definitive treatment was instituted. Treatment based on a definitive or suspected diagnosis reached a satisfactory result; however, the condition can cause a life-threatening situation. When upper gastrointestinal bleeding from an obscure source is encountered, hemosuccus pancreaticus should be considered. We suggest that when an aneurysm of peripancreatic vessels is present, adequate treatment for the aneurysm should be immediately undertaken, even though the site of the bleeding has not been confirmed.
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16
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Lin YH, Chen CY, Chen CP, Kuo TY, Chang FY, Lee SD. Hematemesis as the initial complication of pancreatic adenocarcinoma directly invading the duodenum: A case report. World J Gastroenterol 2005; 11:767-9. [PMID: 15655842 PMCID: PMC4250759 DOI: 10.3748/wjg.v11.i5.767] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pancreatic carcinoma is a debilitating disease and carries a poor prognosis. It is a rare cause of upper gastrointestinal bleeding, even though pancreas, stomach, duodenum and jejunum are adjacent organs. The incidence of pancreatic adenocarcinoma directly invading the gastrointestinal tract leading to gastrointestinal hemorrhage is very low, and most of them present with melena and hematochezia. Here, we describe one unique case manifesting characteristically severe and unremitting hematemesis as an initial presentation of pancreatic adenocarcinoma. This tumor directly invaded the duodenal mucosa as a bleeding protruding tumor mass. Our MEDLINE search has confirmed that this is the first reported case with an initial manifestation of hematemesis from pancreatic adenocarcinoma in Asians. Pancreatic adenocarcinoma directly invading duodenum complicated by hemorrhage can be a rare cause of hematemesis, and clinicians should be reminded of it while they are making differential diagnosis.
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Affiliation(s)
- Yueh-Hung Lin
- Division of Gastroenterology, Taipei Veterans General Hospital, 12F, 201, Sec. 2, Shih-Pai Road, Taipei 112, Taiwan, China
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17
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Vaughan A, Lohr J. Invasive pancreatic cancer presenting as gastrointestinal hemorrhage—a case report. ACTA ACUST UNITED AC 2004; 61:390-2. [PMID: 15276347 DOI: 10.1016/j.cursur.2004.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Upper gastrointestinal hemorrhage is not uncommonly seen by the surgical practitioner. We present a case of a patient who presented with melena and syncope, who was subsequently found to have invasive metastatic pancreatic cancer as his source of bleed.
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Affiliation(s)
- Aislinn Vaughan
- Section of Vascular Surgery, Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio 45220, USA.
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18
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Strömmer L, Albiin N, Calissendorff B, Granlund H, Permert J. Diagnosis and treatment of hemosuccus pancreaticus during a nonbleeding episode: A case report of a patient with obscure intermittent gastrointestinal bleeding and silent chronic pancreatitis. Pancreatology 2004; 4:7-11. [PMID: 14988653 DOI: 10.1159/000077022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hemorrhage from the pancreatic duct, i.e. hemosuccus pancreaticus (HP), is a rare cause of gastrointestinal bleeding. This potentially life-threatening complication of chronic pancreatitis may pose a significant diagnostic and therapeutic dilemma, especially in patients with silent forms of the disease. METHODS We report a case of a 64-year-old man with no history or symptoms but positive findings of chronic calcifying pancreatitis at computed tomography (CT) scan. RESULTS The patient presented with repeated episodes of gastrointestinal bleeding requiring transfusion and did not, until later in the disease, develop hyperamylasemia and epigastric pain. Repeated endoscopies could not reveal the source of bleeding. The radiological diagnosis and successful transcatheter embolization of a small splenic pseudoaneurysm were performed during an interval when the patient was asymptomatic and showed no signs of bleeding. CONCLUSION We suggest that when HP is suspected, a contrast-enhanced CT angiography with reconstruction of the arteries should be performed regardless of whether the patient shows signs of active bleeding or not.
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Affiliation(s)
- Lisa Strömmer
- Department of Surgery, Center for Surgical Sciences at Karolinska Institutet at Huddinge University Hospital, Stockholm, Sweden.
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Affiliation(s)
- Alexander Julianov
- First Department of Surgery, Thracian University Hospital, Stara Zagora, Bulgaria.
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Dasgupta R, Davies NJ, Williamson RCN, Jackson JE. Haemosuccus pancreaticus: treatment by arterial embolization. Clin Radiol 2002; 57:1021-7. [PMID: 12409114 DOI: 10.1053/crad.2002.1063] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM Haemosuccus pancreaticus is bleeding into the pancreatic duct from a peripancreatic artery. This condition most commonly follows pseudoaneurysm formation secondary to acute or chronic pancreatitis. It is a rare disorder, challenging in both diagnosis and therapy. We present an eight-year experience of managing these patients using endovascular embolization as the primary therapy. MATERIALS AND METHODS We retrospectively reviewed the imaging, laboratory results and clinical notes of the five patients who presented to this institution between 1991-1999 with gastrointestinal bleeding subsequently found to be haemosuccus pancreaticus. RESULTS There were four men and one women aged 38-75 years. All had a history of gastrointestinal haemorrhage and had acute (n=1) or chronic pancreatitis with a complicating pseudoaneurysm. All underwent embolization as the primary therapy for the pseudoaneurysm. There was immediate technical success in all cases without major complication. No patient required operative surgery for the pseudoaneurysm. Follow-up ranged from 18 months to 7 years. One patient died four years after embolization due to hepatic failure but the other four remain well without further gastrointestinal bleeding. CONCLUSION Endovascular embolization is an effective and safe treatment for haemosuccus pancreaticus.
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Affiliation(s)
- R Dasgupta
- Department of Surgery, Imperial College, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
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Spencer FAC, Martins Filho E, Santos Júnior MAD, Ferraz EM. Hemosuccus pancreaticus: causa rara de hemorragia digestiva maciça. Rev Col Bras Cir 1999. [DOI: 10.1590/s0100-69911999000200013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
Haemosuccus pancreaticus is a rare complication of pancreatitis. It is a diagnostic problem for even the most astute clinician and a challenge for the expert endoscopist. We report a 25-year-old male patient who had all the features usually seen in haemosuccus pancreaticus patients: recurrent obscure upper gastrointestinal bleeding, pancreatitis, pseudocyst formation, ductal disruption, fistula and pancreatic ascites. The patient was treated by subtotal pancreatectomy, splenectomy and drainage of the pseudocyst. Although pancreatic duct communication with the surrounding vasculature could not be ascertained, we strongly believe the patient had haemosuccus pancreaticus because, over a follow-up period of 3 years, the patient was not only ascites free, but did not experience any further upper gastrointestinal bleeding. We believe that in evaluating patients with recurrent obscure gastrointestinal bleeding, one should always remember that the pancreas is a part of the gastrointestinal tract and, like other organs, is prone to blood loss.
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Affiliation(s)
- G N Yattoo
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Soura, Kashmir, India
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de Perrot M, Bühler L, Deléaval J, Borisch B, Mentha G, Morel P. Management of true aneurysms of the splenic artery. Am J Surg 1998; 175:466-8. [PMID: 9645773 DOI: 10.1016/s0002-9610(98)00082-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Splenic artery aneurysms (SAA) are detected with increasing frequency but their management still remains controversial. This paper relates our experience in the outcome and management of ruptured aneurysms of the splenic artery. METHODS Between 1977 and 1996, 8 patients presented to our institution with a ruptured SAA. Their ages ranged from 25 to 72 years (mean 55 ys). RESULTS All patients presented with rupture as the first sign of SAA. One patient was at 32 weeks of gestation and rupture suggested placental abruption. Three patients required cardiopulmonary reanimation prior to surgical procedures. Splenopancreatectomy (n = 4), splenectomy (n = 2), and ligation of the splenic artery (n = 1) were performed. Seven of the 8 patients survived. Size of aneurysms ranged from 2 cm to 3.5 cm (mean 3 cm). CONCLUSIONS SAA may rupture at any age. Diagnosis during pregnancy rests upon a high index of suspicion. The mortality rate remains low if immediate resuscitation is performed and an aggressive surgical approach is taken.
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Affiliation(s)
- M de Perrot
- Department of Surgery, University Hospital of Geneva, Switzerland
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Abstract
Direct fistula between the splenic, artery and the pancreatic duct is briefly reviewed. The literature indicates that such a fistula is almost always due to a pancreatic artery aneurysm. Because of diagnostic difficulties, a variety of operations have been performed on these patients prior to arriving at the correct diagnosis. A patient's history of direct fistula between the splenic artery and the pancreatic duct, causing recurrent haemorrhage and eventual death from massive blood loss, is described. Unlike other reported cases, this was not associated with an angiographically demonstrable aneurysm of the splenic artery. Treatment by distal pancreatectomy or radiologically guided pancreatic artery embolization is discussed.
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Affiliation(s)
- K B Orr
- St George Hospital, Sydney, New South Wales, Australia
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Lee P, Sutherland D, Feller ER. Massive gastrointestinal bleeding as the initial manifestation of pancreatic carcinoma. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1994; 15:223-7. [PMID: 7930783 DOI: 10.1007/bf02924198] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Pancreatic carcinoma is a rare cause of GI bleeding. We have studied eight patients in whom major digestive hemorrhage was the first sign of a subsequently proven pancreatic malignancy. Bleeding was characteristically severe and unremitting, including hematochezia (four), melena (three), and hematemesis (one). In seven cases, direct tumor invasion into a contiguous portion of the GI tract was present. Tumor erosion occurred into the third portion of the duodenum (three) descending (two), stomach (one), and transverse colon (one). In one patient, a metastatic bleeding lesion was present in the sigmoid colon. The four patients who required urgent laparotomy for control of major hemorrhage died during the initial hospitalization. Conventional diagnostic evaluation by endoscopic and roentgenographic techniques was commonly unsuccessful. Our retrospective analysis suggested that a more aggressive approach, including early angiography in unrelenting and undiagnosed bleeding, might have aided diagnosis and averted laparotomy in a population with dismal prospects for a surgical solution. Clinicians should be aware that pancreatic malignancy may present with a varying spectrum of GI bleeding ranging from occult to potentially exsanguinating hematemesis, hematochezia, or melena.
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Affiliation(s)
- P Lee
- Miriam Hospital, Providence, RI
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Wagner WH, Cossman DV, Treiman RL, Foran RF, Levin PM, Cohen JL. Hemosuccus pancreaticus from intraductal rupture of a primary splenic artery aneurysm. J Vasc Surg 1994; 19:158-64. [PMID: 8301728 DOI: 10.1016/s0741-5214(94)70130-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Hemosuccus pancreaticus--blood entering the gastrointestinal tract through the pancreatic duct--is a rare and elusive form of gastrointestinal bleeding. The most common cause is a splenic artery pseudoaneurysm caused by acute or chronic inflammation of the pancreas. We report the case of an 86-year-old woman who had recurrent gastrointestinal bleeding from erosion of an aneurysm of the splenic artery into the pancreatic duct. The lack of associated symptoms, equivocal endoscopic findings, and the rarity of this entity resulted in a delay in diagnosis. Nonresective treatment by ligation of the splenic artery proximal and distal to the aneurysm prevented any additional bleeding. Postoperative technetium sulfur colloid scanning demonstrated normal perfusion of the spleen. Only 16 cases of hemosuccus pancreaticus from primary splenic artery disease have previously been reported in the English-language literature (15 primary aneurysms, one medial disruption without an aneurysm). In contrast to cases caused by inflammatory pseudoaneurysms, splenic artery-pancreatic duct fistulas caused by primary aneurysms of the splenic artery should be treated without pancreatic or splenic resection, either with surgery or by embolization. In elderly patients with recurrent gastrointestinal bleeding of obscure source, the differential diagnosis should include the possibility of a ruptured aneurysm communicating with a viscus.
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Affiliation(s)
- W H Wagner
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Forsmark CE, Wilcox CM, Grendell JH. Endoscopy-negative upper gastrointestinal bleeding in a patient with chronic pancreatitis. Gastroenterology 1992; 102:320-329. [PMID: 1727767 DOI: 10.1016/0016-5085(92)91818-o] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- C E Forsmark
- Division of Gastroenterology, University of California, San Francisco
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Rosanelli G, Uranüs S, Klein E, Schweiger W. [Hemosuccus pancreaticus]. LANGENBECKS ARCHIV FUR CHIRURGIE 1990; 375:299-302. [PMID: 2259264 DOI: 10.1007/bf00184172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We describe a case of hemorrhage into the pancreatic duct, secondary to a bleeding aneurysm of the splenic artery. The problem of the diagnosis of this rare cause of upper gastrointestinal hemorrhage and therapeutic possibilities with their recurrency and mortality rates under short review of literature are discussed.
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Abstract
The most common complication of chronic pancreatitis is pain, which in many cases seems related to pancreatic ductal obstruction with ductal hypertension. Longitudinal pancreaticojejunostomy is indicated in patients with a dilated (larger than 7 mm) duct and pain that requires narcotic analgesics for relief. Chronic pseudocysts may be corrected surgically without the usual 6-week wait, and asymptomatic pseudocysts less than 4 cm in diameter may not require surgery at all. The relative efficacy and risks of percutaneous drainage of pseudocysts versus the standard surgical approaches need to be studied. Pancreatic fistulas may be external or internal, where pancreatic ascites or hydrothorax can be the clinical manifestation. The pharmacologic suppression of pancreatic secretion (e.g., with somatostatin) may be useful in their management, but surgery may be required. Pancreatic resection or internal drainage is usually effective. Persistent jaundice should be relieved surgically by choledochoduodenostomy to avoid the development of secondary biliary cirrhosis. Obstruction at various levels of the gastrointestinal tract (duodenum, small bowel, colon) may require bypass (gastrojejunostomy) or resection. Hemorrhage from major arteries is an infrequent but often lethal complication of chronic pancreatitis, especially associated with pseudocysts. Angiography is invaluable for diagnosis and occasionally for treatment (embolization). Surgery is preferred in good-risk patients, with suture ligation (resection) of the bleeding source. Chronic pancreatitis is the most common cause of splenic vein thrombosis. The resultant hemorrhage from gastric varices is managed effectively by splenectomy.
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Affiliation(s)
- E L Bradley
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Lancaster JR. Upper Gastrointestinal Bleeding. Prim Care 1988. [DOI: 10.1016/s0095-4543(21)01056-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mandel SR, Jaques PF, Sanofsky S, Mauro MA. Nonoperative management of peripancreatic arterial aneurysms. A 10-year experience. Ann Surg 1987; 205:126-8. [PMID: 3492972 PMCID: PMC1492820 DOI: 10.1097/00000658-198702000-00004] [Citation(s) in RCA: 146] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The surgical approach to bleeding visceral artery aneurysms has a mortality rate of 16-50% that is dependent primarily on anatomic location and underlying cause. Nineteen patients were studied over a 10-year period who were definitively treated by embolization. There was a 79% success rate and no mortality. The cause of the aneurysms was pancreatitis in 13 patients, trauma in four patients, subacute bacterial endocarditis in one patient, and secondary to biliary tract surgery in one patient.
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