1. Radiology Case Presentation Hem Bhardwaj October 15, 2004 Radiology, Period 4

2. HPI: 54yo male presents with hematemesis and melena x 3 days. PMH: h/o alcohol abuse Chronic pancreatitis Chronic pancreatitis Chronic back pain Chronic back pain Social History: Alcohol- 1 pint/day x 20yrs; Tobacco- 2ppd x 25yrs PE: Afebrile; At OSH – midleft epigastric abdominal pain radiating to his back; @ UVA, on admission - PE WNL, benign abdominal exam; day after admission (s/p EGD)- severe (10/10) epigastric pain radiating to back Labs on admission: LFTS WNL; amylase-51, lipase-51 CBC : CBC : 7 77 7 9.2 27.5 239

3. Differential Diagnosis-Upper GI Bleed (UGIB): Includes: Esophagitis/Gastritis Esophagitis/Gastritis Esophageal varices Esophageal varices Mallory-Weiss tear Mallory-Weiss tear Peptic Ulcer Disease Peptic Ulcer Disease Esophageal cancer Esophageal cancer AVM AVM+… First Diagnostic test of choice to evaluate an UGIB EGD This patient’s EGD was negative, so an abdominal CT was done……..

4. Pt W.W.

5. Hemosuccus Pancreaticus ACR Code 77.89 (pancreas.other) Also known as Wirsungorrhaghia (=bleeding into the pancreatic duct) or pseudohemobilia Also known as Wirsungorrhaghia (=bleeding into the pancreatic duct) or pseudohemobilia A very rare cause of UGIB (remember this when you get pimped on rounds) A very rare cause of UGIB (remember this when you get pimped on rounds) First described in early 1930s, term coined in 1970 by Sandblom First described in early 1930s, term coined in 1970 by Sandblom Caused by: 1) erosion of a peripancreatic artery (branches of the celiac trunk) by a pancreatic pseudocyst or 2) caused by the formation of a peripancreatic artery aneurysm with secondary fistula formation with the pancreatic duct. Caused by: 1) erosion of a peripancreatic artery (branches of the celiac trunk) by a pancreatic pseudocyst or 2) caused by the formation of a peripancreatic artery aneurysm with secondary fistula formation with the pancreatic duct. Splenic and gastroduodenal arteries most commonly affected. In this case, the patient had a pseudoaneurysm of the left gastric artery and erosion into the pancreatic duct which lead to the patient’s UGIB. Splenic and gastroduodenal arteries most commonly affected. In this case, the patient had a pseudoaneurysm of the left gastric artery and erosion into the pancreatic duct which lead to the patient’s UGIB. Most common cause is chronic pancreatitis. Local inflammation induces pseudoaneurysm formation. Most common cause is chronic pancreatitis. Local inflammation induces pseudoaneurysm formation.

6. Hemosuccus Pancreaticus (cont’d) Diagnostic tests include: Diagnostic tests include: -EGD (difficult to see hemosuccus pancreaticus) -EGD (difficult to see hemosuccus pancreaticus) -ERCP -ERCP -Abdominal CT -Abdominal CT -Angiography -Angiography Radiologically, if a pseudoaneurysm distorting the pancreatic border is observed (most likely by CT) and if this occurs in the context of a patient with chronic pancreatitis with an UGIB consider hemosuccus pancreaticus. Radiologically, if a pseudoaneurysm distorting the pancreatic border is observed (most likely by CT) and if this occurs in the context of a patient with chronic pancreatitis with an UGIB consider hemosuccus pancreaticus. Management includes angiographic embolization and possibly surgery if embolization fails or there are other pancreas-related indications for surgery (ex. suspicion of malignancy) Management includes angiographic embolization and possibly surgery if embolization fails or there are other pancreas-related indications for surgery (ex. suspicion of malignancy)

7. Pt W.W.--Successful left gastric pseudoaneursym embolization with microcoils.

8. References: Raman L et al. Pseudoaneurysm of the Superior Pancreaticoduodenal Artery, a rare cause of Hemosuccus pancreaticus. Report of a case. Surgery Today. 34(2):181-184, 2004. Koizumi J et al. Hemosuccus pancreaticus: diagnosis with CT and MRI and treatment with transcatheter embolization. Abdominal Imaging. 27:77-81, 2002. Sarkorafas GH et al. Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper GI bleeding. Langenbecks Archives of Surgery. 385(2):124-128, March 2000.