Radiology Case PresentationRadiology Case Presentation

Hem BhardwajHem Bhardwaj

October 15, 2004October 15, 2004

Radiology, Period 4Radiology, Period 4

HPI: 54yo male presents with hematemesis and melena x 3 days.HPI: 54yo male presents with hematemesis and melena x 3 days.

PMH: h/o alcohol abusePMH: h/o alcohol abuse

Chronic pancreatitisChronic pancreatitis

Chronic back painChronic back pain

Social History: Alcohol- 1 pint/day x 20yrs; Tobacco- 2ppd x 25yrsSocial History: Alcohol- 1 pint/day x 20yrs; Tobacco- 2ppd x 25yrs

PE: Afebrile; At OSH – midleft epigastric abdominal pain radiating to his back; @ UVA, 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 on admission - PE WNL, benign abdominal exam; day after admission (s/p EGD)- severe (10/10) epigastric pain radiating to back(10/10) epigastric pain radiating to back

Labs on admission: LFTS WNL; amylase-51, lipase-51Labs on admission: LFTS WNL; amylase-51, lipase-51

CBCCBC:: 77

9.29.2

27.527.5239239

Differential Diagnosis-Upper GI Bleed (UGIB):Differential Diagnosis-Upper GI Bleed (UGIB):

Includes:Includes: Esophagitis/GastritisEsophagitis/Gastritis Esophageal varicesEsophageal varices Mallory-Weiss tearMallory-Weiss tear Peptic Ulcer DiseasePeptic Ulcer Disease Esophageal cancerEsophageal cancer AVM AVM

+…+…

First Diagnostic test of choice to evaluate an UGIB EGDFirst Diagnostic test of choice to evaluate an UGIB EGD

This patient’s EGD was negative, so an abdominal CT was done……..This patient’s EGD was negative, so an abdominal CT was done……..

Pt W.WPt W.W..

Hemosuccus PancreaticusHemosuccus PancreaticusACR Code 77.89 (pancreas.other)ACR Code 77.89 (pancreas.other)

Also known as Wirsungorrhaghia (=bleeding into the pancreatic duct) or Also known as Wirsungorrhaghia (=bleeding into the pancreatic duct) or pseudohemobiliapseudohemobilia

A very rare cause of UGIB A very rare cause of UGIB (remember this when you get pimped on rounds)(remember this when you get pimped on rounds)

First described in early 1930s, term coined in 1970 by SandblomFirst 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 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 pancreatic pseudocyst or 2) caused by the formation of a peripancreatic artery aneurysm with secondary fistula formation with the pancreatic duct.aneurysm with secondary fistula formation with the pancreatic duct.

Splenic and gastroduodenal arteries most commonly affected. In this case, the Splenic and gastroduodenal arteries most commonly affected. In this case, the patient had a pseudoaneurysm of the left gastric artery and erosion into the patient had a pseudoaneurysm of the left gastric artery and erosion into the pancreatic duct which lead to the patient’s UGIB.pancreatic duct which lead to the patient’s UGIB.

Most common cause is chronic pancreatitis. Local inflammation induces Most common cause is chronic pancreatitis. Local inflammation induces pseudoaneurysm formation.pseudoaneurysm formation.

Hemosuccus Pancreaticus (cont’d)Hemosuccus Pancreaticus (cont’d)

Diagnostic tests include:Diagnostic tests include: -EGD (difficult to see hemosuccus pancreaticus)-EGD (difficult to see hemosuccus pancreaticus) -ERCP-ERCP -Abdominal CT-Abdominal CT -Angiography-Angiography

Radiologically, if a pseudoaneurysm distorting the pancreatic border is Radiologically, if a pseudoaneurysm distorting the pancreatic border is observed (most likely by CT) and if this occurs in the context of a patient observed (most likely by CT) and if this occurs in the context of a patient with chronic pancreatitis with an UGIB consider hemosuccus with chronic pancreatitis with an UGIB consider hemosuccus pancreaticus.pancreaticus.

Management includes angiographic embolization and possibly surgery if Management includes angiographic embolization and possibly surgery if embolization fails or there are other pancreas-related indications for embolization fails or there are other pancreas-related indications for surgery (ex. suspicion of malignancy)surgery (ex. suspicion of malignancy)

Pt W.W.--Successful left gastric pseudoaneursym embolization with microcoils.Pt W.W.--Successful left gastric pseudoaneursym embolization with microcoils.

References:References:

Raman L et al. Pseudoaneurysm of the Superior Raman L et al. Pseudoaneurysm of the Superior Pancreaticoduodenal Artery, a rare cause of Hemosuccus Pancreaticoduodenal Artery, a rare cause of Hemosuccus pancreaticus. Report of a case. Surgery Today. pancreaticus. Report of a case. Surgery Today. 34(2):181-184, 2004.34(2):181-184, 2004.

Koizumi J et al. Hemosuccus pancreaticus: diagnosis with Koizumi J et al. Hemosuccus pancreaticus: diagnosis with CT and MRI and treatment with transcatheter CT and MRI and treatment with transcatheter embolization. Abdominal Imaging. 27:77-81, 2002.embolization. Abdominal Imaging. 27:77-81, 2002.

Sarkorafas GH et al. Hemosuccus pancreaticus Sarkorafas GH et al. Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of complicating chronic pancreatitis: an obscure cause of upper GI bleeding. Langenbecks Archives of Surgery. upper GI bleeding. Langenbecks Archives of Surgery. 385(2):124-128, March 2000.385(2):124-128, March 2000.