Hemosuccus Pancreaticus From the Minor Papilla: A Rare Cause of Upper Gastrointestinal Bleed

CASE REPORT A 59-year-old man with alcohol-related cirrhosis and a previously seen pancreatic mass presented with coffee-ground emesis accompanied by stable hemoglobin at 8.4 g/dL. Upper endoscopy with a standard gastroscope visualized blood in the duodenum without a source. Afterward, a side-viewing duodenoscope visualized a normal major papilla (Figure 1). Subsequently, active bleeding from the minor papilla was identified (Figure 2). Computed tomography angiography revealed a bilobed hematoma and peripancreatic pseudoaneurysm extending from the splenic artery (Figure 3). Coil embolization resulted in near-complete resolution of flow on repeat angiogram (Figure 4).Figure 1.: Side-viewing duodenoscope demonstrating the major papilla without bleeding (dotted blue circle).Figure 2.: Side-viewing duodenoscope revealing bleeding arising from the minor papilla (dotted blue circle).Figure 3.: Computed tomography angiography demonstrating a pseudoaneurysm originating from the splenic artery measuring 2.4 × 1.6 cm (red arrow).Figure 4.: Postembolization angiogram demonstrating resolution of flow through the proximal splenic artery (red arrow).Hemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding (1/1,500) defined by bleeding from the ampulla of Vater through the pancreatic duct and even more rarely emits from the minor papilla.1,2 Risk factors include chronic and recurrent acute pancreatitis, peripancreatic collections, and pancreatic malignancies.2 Clinical presentation often includes intermittent, repetitive hemorrhage, more frequently with melena than hematemesis.1 Endoscopy is crucial to rule out other causes of upper gastrointestinal bleeding and can infrequently identify hemorrhage from the duodenal ampulla, although angiography is the diagnostic gold standard with a 96% sensitivity.2 In hemodynamically stable patients, angioembolization is the preferred choice of therapy; although in cases of instability or failed embolization, patients should undergo hemostatic surgery.1–3 DISCLOSURES Author contributions: N. Reddy authored and drafted the manuscript. G. Kim and U. Siddiqui edited critical aspects of the manuscript. N. Reddy, M. Ryan, S. Nagpal, and U. Siddiqui cared for the patient in the hospital and assisted with acquisition of data for the work. U. Siddiqui contributed to conception and design of the manuscript, interpretation of images, and final approval of the article. N. Reddy is the article guarantor. Financial disclosure: U. Siddiqui has the following disclosures: Boston Scientific—consultant, research support, and speaker; ConMed—consultant and speaker; Cook—consultant and speaker. Medtronic—consultant and speaker. Olympus—consultant, research support, and speaker. All other authors have no financial disclosures or conflicts of interest. Previous presentation: This case was previously presented as an oral presentation for American College of Physicians, Northern Illinois Chapter Conference; October 7, 2022; Chicago, Illinois, and as a poster at the American College of Gastroenterology Annual Scientific Meeting; October 22, 2023; Vancouver, Canada. Informed consent was obtained for this case report.

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