An unusual cause of hemosuccus pancreaticus diagnosed by endoscopic ultrasonography: splenic arterial fistula due to a pancreatic stent (with video)

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We report the case of a 54-year-old woman recently diagnosed with severe acute biliary pancreatitis requiring surgical necrosectomy and caudal pancreatectomy 1 month later. After surgery the patient developed an internal pancreatic fistula which was treated with octreotide (Sandostatin) and percutaneous drainage. Two months later she was diagnosed with a large pancreatic pseudocyst communicating with the pancreatic duct. A transpapillary plastic stent was placed with favorable outcome. After 2 months intermittent rectal bleeding occurred.

The patient was hospitalized 3 weeks after the onset of the intermittent rectal bleeding, with normal blood pressure and severe anemia (hemoglobin 6.9 g/dL). Upper gastrointestinal endoscopy showed the presence of the pancreatic stent and blood in the second part of the duodenum, coming out of the papilla ([Fig. 1]).

Fig. 1 Presence of the pancreatic plastic stent in the second duodenum.

Because there was no possibility of emergent CT or MRI examination, endoscopic ultrasonography (EUS) was performed and showed the plastic pancreatic stent in the pancreatic duct with the distal end in the splenic artery ([Figs. 2 5], [Video 1]).

Fig. 2 Stent visible inside a hypoechoic pancreatic structure (arrowhead).

Fig. 3 Distal end of the stent (arrowhead) visible inside the splenic artery (SA).

Fig. 4 Distal end of the stent (arrowhead) visible inside the splenic artery (SA), with the left adrenal gland nearby.

Fig. 5 Distal end of the stent (arrow) visible inside the splenic artery (SA), with the collateral circulation in the splenic hilum nearby.

Video 1 During endoscopic ultrasonography the plastic pancreatic stent in the pancreatic duct is visible as a parallel hyperechoic structure, crossing a hypoechoic structure (hematoma) and with the distal end in the splenic artery (vascular hypoechoic structure with Doppler and power Doppler signal).

Urgent laparotomy was performed and confirmed that the splenic artery wall had been penetrated by the pancreatic stent; there was a large old hematoma around it. Distal pancreatectomy with double ligation of the splenic artery and splenectomy were successfully performed with favorable outcome immediately and 3 months later.

Hemosuccus pancreaticus is defined as papillary bleeding from the pancreatic duct [1]. The main causes are divided into those of pancreatic origin (rupture into the pancreatic duct of a pseudoaneurysm associated with acute or chronic pancreatitis, arteriovenous malformations, pancreatolithiasis, tumors or bleeding after EUS fine-needle aspiration for cystic lesions) and those of extrapancreatic origin (rupture of a true splenic aneurysm) [2] [3].

This is the first report of a splenic arterial fistula caused by penetration of a pancreatic stent after resolution of the pancreatic collection, diagnosed by EUS, and treated surgically. Other ways of treatment could be transarterial catheter embolization with implantation of a coil or prosthesis, local injection of Histoacryl, or pancreatic resection [4] [5].

Competing interests: None

Endoscopy_UCTN_Code_CPL_1AK_2AJ

References

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• 2 Massani M, Bridda A, Caratozzolo E. et al . Hemosuccus pancreaticus due to primary splenic artery aneurysm: a diagnostic and therapeutic challenge.  JOP. 2009;  10 48-52
• 3 Cheruvattath R, Diehl D L. Hemosuccus pancreaticus after EUS-FNA of a pancreatic tail cyst.  Gastrointest Endosc. 2009;  70 817
• 4 Tabrizian P, Reiter B C, Heimann T M. Multimodality treatment for hemosuccus pancreaticus.  Am J Gastroenterol. 2009;  104 1060
• 5 Will U, Mueller A K, Grote R. et al . “Hemosuccus pancreaticus” – primarily ultrasound-guided successful intervention using transcutaneous fibrin glue application and histoacryl injection.  Ultraschall Med. 2008;  29 260-263