Haemosuccus pancreaticus is a rare complication of acute or chronic pancreatitis, predominantly observed in men (sex ratio 7:1), associated with chronic alcohol consumption (Vimalraj et al. 2009). Clinical symptoms include upper gastrointestinal bleeding, non-specific epigastric pain, hematemesis and melena (Singh et al. 2016). As hemorrhage is usually only intermittent and not severe enough to cause hemodynamic instability, diagnosis is frequently delayed and difficult to make (Vimalraj et al. 2009), as observed in our reported case.
Although endoscopy may reveal bleeding from the papilla, the actual source will typically remain unclear. Nevertheless, other significant causes of upper gastrointestinal bleeding (e.g. erosive gastritis, esophageal and gastric fundus varices or ulcers) may be excluded. Contrast enhanced computed tomography allows for reliable detection of pancreatic pathologies, as well as the assessment of potential complications of chronic pancreatitis while visualizing the peripancreatic vessels. Finally, angiographic intervention (including coil/glue embolization) is the therapy of choice for gastrointestinal bleeds not manageable by endoscopy (Yoshida et al. 2018). Haemosuccus pancreaticus, especially if caused by a pseudoaneurysm, is a potentially life-threatening disease (Subasinghe et al. 2012). Both interventional radiological and surgical approaches are proven therapeutic options. Parent vessel occlusion by means of coil embolization is the most frequently described technique to treat pseudoaneurysm associated HP (Yoshida et al. 2018). This technique was avoided in the current case due to the risk of splenic infarction. Covered stents, an alternative option in the management of pseudoaneurysms arising from larger vessels, offer the advantage of preserving arterial flow and can be used in selective cases to bridge time until elective surgery (De Rosa et al. 2012). However, active pancreatico-arterial fistulas, as suspected in the current case, may lead to graft infections. Furthermore, stent/stent graft delivery into peripheral pseudoaneurysms is technically challenging due to the typically torturous course of the splenic artery. In this regard, Benz et al. described the first successful implantation of an uncoated metal palmaz stent across the aneurysmal segment of the splenic artery for treatment of pseudoaneurysm (Benz et al. 2000).
The probability of a recurrent bleeding after catheter assisted embolization varies between 0 and 30% depending on the reference literature (Vimalraj et al. 2009). In order to completely occlude the pancreatico-arterial fistula we additionally employed tissue adhesive embolization (Histoacryl/Lipiodol; ratio 1:5; 0,4 ml). By doing so, we did not only occlude the pseudoaneurysm, but also the underlying fistula. Ideally, this also stopped pathologic excretion of elastase and autodigestion, thus possibly reducing the risk of recurrence. The patient additionally received trans-splenic portal venous reconstruction and trans jugular porto-systemic shunt 16 months following embolization of splenic artery pseudoaneurysm. In follow up imaging the pseudoaneurysm remained occluded, no further episodes of HP were reported. Data regarding additional fluid embolization in such cases is sparse. Although the current results are promising, the risk of splenic infarction and dislocation or superinfection of glue has to keep in mind.
In patients with persistent unstable hemodynamics, recurrent bleeding or failed embolization, surgical management should be instituted without delay (Vimalraj et al. 2009).