Introduction: Evaluation for gastrointestinal (GI) bleeding occurs on a daily basis. We present a rare case of a life threatening bleed. Case Report: 64-year-old man with history of vascular disease s/p multiple stents, hypertension, and alcoholic pancreatitis presented for catheterization due to vascular complaints. He was found to have a hemoglobin of 6.9 mg/dl. He reported intermittent hematemesis and melena for the last 6 months. On exam, he was in mild distress, heart rate 100 bpm, BP 123/56 mmHg, with epigastric tenderness. Other labs were normal except for a lipase of 675 U/L. EGD was normal except for pooled blood in the second portion of the duodenum. A side viewing endoscope showed blood emerging from the ampulla interspersed with bile. Angiography revealed a pseudoaneurysm of the gastroduodenal artery. The diagnosis was consistent with hemosuccus pancreaticus (HP). He underwent successful embolization. MRI revealed chronic pancreatitis. Discussion: HP is defined as GI bleed via the pancreatic duct. It's a rare cause of bleeding with ~ 100 cases reported. Most common causes are acute and chronic pancreatitis. Tumors, vascular disease, iatrogenic, congenital anomalies, infections, and trauma are rare causes. The pathophysiology is related to pseudoaneurysm formation due to auto-digestion into the peri-pancreatic vessels. The pseudoaneurysm communicates with the pancreatic duct through the pseudocyst or a fistula. Once bleeding occurs, the blood coagulates and obstructs the duct. This leads to increase pressure temporarily tamponading the hemorrhage. As the clot dissolves, hemorrhage recurs, resulting in intermittent bleeding. Patients may present with abdominal pain, GI bleeding and/or hyperamylasemia. Prompt angiography and treatment with angiographic embolization of pseudoaneurysms or surgery is warranted to control bleeding. Failure to recognize and treat HP is associated with mortality up to 90%, declining to 8-37% with treatment. Conclusion: HP should be considered in all patients with a history of pancreatic disease and severe GI bleeding when routine endoscopic findings are non-diagnostic.
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