Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic pseudocysts

Gastrointestinal hemorrhage secondary to hemosuccus pancreaticus is a rare condition that poses a significant diagnostic and therapeutic challenge. It is reported to occur most commonly in the setting of acute or chronic pancreatitis with rupture of pseudoaneurysms of the spleen or hepatic artery into the pancreatic duct. In this report three such cases have been reported. Abdominal ultrasound and CT scanning can noninvasively define pancreatic pseudocysts with a high degree of accuracy. Real-time ultrasonography may document a pulsatile pseudoaneurysm. Radionuclide arterial scanning, by demonstrating pooling of blood in the area of a pseudocyst, can point to the source of bleeding in patients with pancreatitis and gastrointestinal hemorrhage. Selective celiac angiography, however, is the only diagnostic test that can definitively outline a pseudoaneurysm and demonstrate its rupture into a pseudocyst or into the pancreatic duct. Pancreatic resection including excision of the pseudoaneurysm and pseudocyst (when present) is the treatment of choice. In cases where resection is not possible, ligation of the artery proximal and distal to the pseudoaneurysm and drainage of the pseudocyst into the gastrointestinal tract is an acceptable alternative procedure. Although intraarterial catheter embolization of the bleeding vessel can be a lifesaving procedure in these very sick patients, subsequent resection of the lesion is warranted as the definitive treatment.