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INTERVENTIONAL RADIOLOGY Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 921-924
Hemosuccus pancreaticus - endovascular treatment by transcatheter embolization of both gastric arteries


Department of Diagnostic Imaging, Internal Medicine and Surgery, University Hospital Motol, Prague, Czeech Republic, India

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Date of Submission19-Oct-2006
Date of Acceptance30-Nov-2006
 

Keywords: Hemosuccus pancreaticus, Embolization, Pancreatic pseudoaneuryzma, Pancreatic pseudocyst

How to cite this article:
Janik V, Padr R, Adla T, Neuwirth J, Keil R, Lischke R, Pafko P. Hemosuccus pancreaticus - endovascular treatment by transcatheter embolization of both gastric arteries. Indian J Radiol Imaging 2006;16:921-4

How to cite this URL:
Janik V, Padr R, Adla T, Neuwirth J, Keil R, Lischke R, Pafko P. Hemosuccus pancreaticus - endovascular treatment by transcatheter embolization of both gastric arteries. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:921-4. Available from: http://www.ijri.org/text.asp?2006/16/4/921/32385
Acute bleeding into the gastrointestinal tract is a rare but fatal complication of pancreatitis [1]. It is caused by communication between a peripancreatic artery and the pancreatic system due to arterial arosion by lytic enzyme or pressure of a growing pseudocyst [2]. Since 1970, when Sandblom described 3 cases of gastrointestinal bleeding from the pancreatic duct, the term hemosuccus pancreaticus has been used for such bleeding [3].

In our case a patient with chronic pancreatitis developed acute bleeding into the gastrointestinal tract to the perforation of a pseudoaneurysm into pancreatic pseudocyst in the area of the pancreatic body. The diagnosis of hemosuccus pancreaticus established by endoscopy and postcontrast CT examination was confirmed by angiography. We stopped the acute bleeding from the pseudoaneurysm, unusually well supplied by both gastric arteries, by embolizing both arteries with metallic coils.


   Material and Method Top


The man patient, aged 49, with a history of chronic pancreatitis, was admitted with hematenesis and a growing pain in the epigastrium. Emergency gastofibroscopy diagnosed hemobilia as the cuase of hematemesis. Laboratory results showed pronounced anemia - Hb 76 g/1 and HCT 0.21%, and elevated bilirubin level at 25 um/1. The patient was treated conservatively by blood derivatives and hemostyptics. After a temporary stablization the patient was again becoming anemic and melena appeared. Endoscopic retrograde cholangiopancreatography (ERCP) revealed bleeding from the papilla of Vater and after the application of contrast material a 4 cm long suprapapillary stenosis of the choledochus with a 12 mm dilatation of ductus hepaticus communis showed. We introduced a plastic internal 10 F endoprosthesis into the biliary system. Since clear bile was discharged from the outler of the endoprosthesis while spot bleeding from the papilla of Vater persisted, the patient was immediately refrred for a CT examination.

Postcontrast CT revealed, in the area of the pancreatic body, a round pseudocyst of 61 x 58 mm in which an oval eccentrically located pseudoaneurysm of 15 x 10 mm became dyed [Figure - 1].

In angiography, we first introduced a 4F Cobra catheter (William Coo,, Europe) into arteria lienalis but no pseudoaneurysm showed. After introducing the catheter into truncus coeliacus in the basin of the left gastric artery arteria, a pseudoaneurysm of 3 x 2 cm showed in contrast, located in the area of the pancreatic body [Figure - 2], as first revealed by the CT finding. In selective angiography of the left gastric artery the pseudoaneurysm was being filled by small branches of that artery, while the wound the right gastric artery was filling retrogradely at the same time. We first embolized the stem of the left gastric artery by 4 metallic coils, 30 mm long and 3 mm in diameter (William Cook, Europe). Since the pseudoaneurysm was also filling in selective angiogrpahy of the right gastric artery [Figure - 3], we embolized this artery too by 5 metallic coils of the same size. In follow-up angiography after the embolization the pseudoaneurysm did not show in contrast any more [Figure - 4].

In postcontrast CT performed 5 days after the embolization the pseudoaneurysm is not becoming dyed in contrast (Fig 5). On the 20th day of hospitalization, the patient, not experiencing any problems, was discharged to home care.

In a follow-up postcontrast CT performed 2 years after the embolization the pancreatic pseudocyst had regressed and the pseudoaneurysmdisappeared (Fig.6). Throughout that time the patient has been asymptomatic and experienced no further episode of bleeding into the gastrointestinal tract.


   Discussion Top


Hemorrhagic complications of chroni pancreatitis are caused by a combination of local ischemia and partial digestion of the arterial wall by pancreatic enzymes [4]. Bleeding caused by arosion of one of the pancreatic arteries can flow into the pancreatic duct system directly, into retroperitoneum or into a pseudocyst, either communicating or not with the pancreatic duct [1]. Hemobilia may rarely occur, accompanied by biliary colic and icterus. Lienal artery is the most frequent scurcre of bleeding (45%), followed by gastroduodenal artery (17%) and pancreaticoduodenl artery (16%) [4]. Rarely, bleeding can originate in the supply branches of gastric arteries, renal artery, portal vein or directly in the aorta.

Progressing inflammatory changes and partial digestion of the arterial wall by panreatic enzymes result in the development of a pseudoaneurysm on one of the peripancreatic arteries. Rupture of the pseudoaneurysm is a major complication associated with high mortality reaching 90% in untreated and 12,5% in treated patients [4]. Perforation of a small pseudoaneurysm located in the pseudocyst usually transforms the pseudocuyst into a sizeable pseudoaneurysm. Bleeding into the pseudocyst Occurs in 4-6% of patients with chronic pancreatitis [1]. Spontaneous perforation of a pseudocyst communicating with arterial blood supply to the pancreatic duct, gastrointestinal tract, peritoneal cavity or retroperitoneum is a major, often fatal complication.

A number of imaging methods provide evidence of the cause of bleeding into the gastrointestinal tract in patients with chronic pancreatitis. Colour Doppler coding can reveal a pulsating cystic lesion of pseudoaneurysmic nature [5]. The place of bleeding from the aroded artery can also be detected by technetium 99m. Endoscopy and endoscopic retrograde cholangiopancreatography (ERCP) can detect blood flowing from the papilla of Vater [6]. Contrast enhanced CT appears to be the most valuable method showing bleeding into pseudocyst and pseudoaneurysm. Angiography shows the aroded arteries filling the pseudoaneurysm and their communication with the pseudocyst or the pancreatic duct [1]. The sensitivity of identification of a bleeding artery in angiography is 96% [6].

Bleeding complications can be treated conservatively, surgically or through catheterization. Conservative treatment is burdened with 90% mortality [4]. Surgical treatment is based on artery ligation proximally and distally from the place of bleeding and on a partial or total resection of the pancreas. Some authors prefer surgical solutions in patients with pancreatic pseudoaneurysm and obstructive icterus [5]. Surgical solutions are associated with a 35-50% morbidity and mortality in hemodynamically unstable patients [7]. Therefore, an acute surgical solution is usually reserved for cases where embolization is technically unfeasible or where recurrent bleeding occurs.

Catheter embolization of the bleeding artery is currently regarded as the method of first choice [1]. The embolization of aroded artery is performed in order to achieve immediate therapeutic effect and to create favourable conditions for a subsequent final surgical solution [4].

Metallic coils, gelfoam, N-butyl-2-cyanoacrylate, balloon catheters are used to embolize the bleeding artery, or the neck of the aneurysm can be closed with a coated metallic stent [1],[6]. As a prerequisite, the artery must be closed, both proximally and distally from the pseudoaneurysm, for optimal embolization results [1]. Ultrasound-guided percutaneous thrombin injection has been used successfully to close the pancreatic pseudoaneurysm [8].

Post-embolization complications in peripancreatic arteries are very limited [3],[6]. Parenchymal or intestinal necrosis can rarely developed, induced by a leak of the embolizing material to other arteries [1],[4].

Finally, it is noted that angiography plays an irreplaceable role in patients with hemosuccus pancreaticus. Our case involved a rate instance of bleeding from a pseudoaneurysm supplied by both gastric arteries. Their embolization produced an immediate hemostasis and improvement in the patient's condition, with the original pseudocyst with pseudoaneurysm diasppearing within 2 years.[10]

 
   References Top

1.Balthazar EJ, Fisher LA. Frey C. Hemorrhagic complication of pancreatitis: radiological evaluation with emphasis on CT Imaging. Pancreatology 2001;1(4): 3006-3013.  Back to cited text no. 1    
2.Dasgupta R, Davis NJ, Williamson RCN, Jackson JE, Haemosuccus Pancreaticus: Treatment by Arterial Embolization. Clinical Radiology 2002;57:1021-1027.  Back to cited text no. 2    
3.Sandblom P, Gastrointestinal Haemorrhage through the pancreatic duct. Ann Surg 1970;171:61-66.  Back to cited text no. 3    
4.Suguki T, Hatori T, Imaizumi T, Harada N, Fukuda A, Kamikozuru H, et al. Two cases of hemosuscus pancreaticus in which hemostasis was achieved by transcatheter arterial embolization. J. Hepatobiliary Pancreat Sug 2003;10:450-454.  Back to cited text no. 4    
5.Yamaguchi K, Futagawa S, Ochi M, Sakamoto l, Hayashi K. Pancreatic Pseudoaneurysm Converted from Pseudocyst: Transcatheter Embolization and Serial CT Assessment. Radiation Medicine, 2000;Vol,18,No 2, 147-150.  Back to cited text no. 5    
6.Safoiu A, Iordache S, Ciurea T, Dumitrescu D, Popesucu M, Stoica Z. Pancreatic Pseudoaneurysm of the Superior Mesenteric Artery Complicated with Obstructive Jaundice. A Case Report. Journal of Pancreas 2005;6(1):29-35.  Back to cited text no. 6    
7.Kaman L, Sanyal S, Manekuru SR, Singh R. Pseudoaneurysm of the Superior Pancreaticoduodenal artery, Rare Cause of Hemosuccus Pancreaticus: Report of a Case Surg. Today 2004;34:181-184.  Back to cited text no. 7    
8.Maleux G, van Steenbergen W, Stockx L, Vanbeckevoort D, Wilms G, Marchal G. Multiple small pseudoaneurysm complicating pancreatitis: angiographic diagnosis and transcatheter embolization. Eur. Radiol. 2000;10,1127-1129.  Back to cited text no. 8    
9.Bender JS, Bouwman DL, Levison MA. Pseudocyusts and pseudoaneurysms: Surgical strategy. Pancreas 1995;10,143-147.  Back to cited text no. 9    
10.Sparrow P, Asquith J, Chalmers N. Ultrasonic - Guided Percutaneous Injection of Pancreatic Pseudoaneurysm with Thrombin. Cardiovasc. Intervent. Radiol. 2003;26:312-315.  Back to cited text no. 10    

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Correspondence Address:
V Janik
Department of Diagnostic Imaging, Internal Medicine and Surgery, University Hospital Motol, Prague, Czeech Republic
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32385

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]



 

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