ARRS Case of the Week- Mar 19, 2018

GASTROINTESTINAL IMAGING: Pancreas

Case Author: Ramit Lamba, MBBS, MD, University of California, Davis

History

57-year-old man with chronic pancreatitis and severe abdominal pain, nausea, vomiting, low hematocrit, and bleeding at the jejunostomy site after recent abdominal surgery for mesenteric ischemia; CT has been performed and the next step must be determined.

Imaging Findings

Axial CT image through the abdomen (A) shows a markedly atrophic pancreas with diffuse parenchymal and ductal calcifications (arrowheads). Axial CT angiogram (B) caudal to A shows a focal area of enhancement (arrow) similar to the blood pool surrounded by a hyperattenuating collection (asterisk). High-density material (arrowheads) is evident in the duodenal lumen.

Diagnosis

Selective mesenteric angiography and embolization

Teaching Points

Hemosuccus pancreaticus is a rare cause of intermittent upper gastrointestinal bleeding. If the source of bleeding is obscure, hemosuccus pancreaticus should be included in the differential diagnosis, especially if the patient has acute or chronic pancreatitis. It commonly is caused by leaking pseudoaneurysm of the splenic and mesenteric branches of the celiac axis or proximal superiormesenteric artery.

Hemorrhage is a rare, usually late but potentially fatal complication of pancreatitis.

Hemorrhage in pancreatitis occurs as a result of leaking or rupture of a pseudoaneurysm, directarterial erosion, or bleeding in pancreatic necrosis or into a pseudocyst.

Endovascular coil embolization is the current interventional standard for treatment of a pseudoaneurysm.

Schedules and Media