Upper GI Haemorrhage: A Bleeding Mystery !!

Upper GI Haemorrhage: A Bleeding Mystery !! Yoke Lim ST3 Radiology Dr Appu Rudralingam Consultant Radiologist Dr Haider Alwan-WalkerConsultant Radiologist Manchester Foundation Trust (Wythenshawe Hospital)

Mr SL • 44 years, Male • Presented with fatigue, long standing epigastric discomfort, haematemesis & melaena. • Previous pancreatitis, excessive alcohol intake (32 units/week) • Initial bloods • Hb 39, MCV 70, WCC 2.6, Plt 187

Initial Management Figure 1A & B: Normal oesophago-gastro-duodenoscopy (OGD) and colonoscopy.

ct * Figure 2A & B: CT Axial and Coronal demonstrating pseudo-aneurysm (white arrow) in the left gastric artery, directly superior to the pancreas (asterisk).

Angiographic embolisation Figure 3A & B: Catheter angiogram confirming left gastric pseudo-aneurysm (white arrow), which was successfully coiled (black arrow).

Readmission… • Despite embolization, he represented with a further episode of UGI bleed • Hb 51 • Normal OGD • Repeat CT angiogram

ct Figure 4A & B: CT Axial images demonstrating recurrence of left gastric pseudo-aneurysm (white arrow), despite previous embolization (black arrow).

Angiographic embolisation Figure 5A & B: Catheter angiography illustrates recurrence of left gastric pseudo-aneurysm (black arrow) and recanalization of the left gastric artery pass the coil (white arrow). Successful embolization achieved with Onyx TM (white arrow head).

Readmission 2… • 3 months later, further admission with melaena. • Hb 74 • Normal OGD. • Tc RBC scan raises the possibility of small bowel haemorrhage. • Normal capsular endoscopy. • Decision for single balloon enteroscopy

Single balloon enteroscopy Figure 6A & B: Selected images from single balloon enteroscopy revealing clot in the 2nd part of the duodenum. Active bleeding from the ampulla of Vater seen once clot is retrieved.

Haemosuccuspancreaticus

Haemosuccuspancreaticus • Rare cause of UGI bleeding. • Bleeding from ampulla of Vater • Causes • Chronic pancreatitis – formation of pseudoaneurysm. • Vascular malformation • Pancreatic tumour • Iatrogenic/ trauma • Source of pseudoaneurysm • Splenic (40%) • Gastroduodenal (30%) • Pancreaticoduodenal (20%) • Gastric (5%) • Hepatic (2%)

Haemosuccuspancreaticus • Symptoms • Intermittent repetitive UGI bleed – difficult diagnosis • Melaena – most common • Haematemesis • Epigastric pain • Diagnosis • Clinical • Radiology • Cross sectional imaging • Cause • Acute bleeding • Angiography • Pseudoaneurysm • Endoscopy • Bleeding from ampulla of Vater • Rule out other causes of UGI bleeding

Haemosuccuspancreaticus • Management • Interventional radiology • Angiographic embolization • Immediate success rate - > 60% • Recurrence rate – 30% • Complication - ischaemia • Surgery • Unsuccessful embolization, uncontrolled haemorrhage • Other surgical indications – pseudocyst, abscess, obstructive jaundice, GO obstruction • Success rate – 70 – 85% • Rebleeding rate – < 5%

Learning points • Haemosuccus pancreaticus is a rare cause, but an important differential for UGI bleeding. • Challenging diagnosis due to its intermittent nature and obscure bleeding into the main pancreatic duct. • Endoscopy remains the gold standard, but radiology plays an essential role in diagnosis and management.

reference • Rahul Kothari et al. Hemosuccus pancreaticus: a rare cause of gastrointestinal bleeding. Ann Gastroenterol 2012; 25(4): 1-3 • Ashwin Rammohan et al. Hemosuccus Pancreaticus: 15-Year Experience in a Tertiary Care GI Bleed Centre. ISRN Radiology 2013

Upper GI Haemorrhage: A Bleeding Mystery !!