Haemosuccus pancreaticus due to aberrant vessels from the coeliac trunk: a rare cause of Gastrointestinal (GI) bleeding with diagnostic and therapeutic challenges
A 63-year-old male who had been investigated for iron deficiency anaemia of 1 year duration presented with repeated bouts of melaena. He was a hypertensive for which he was on regular antihypertensive treatment. He did not give a past history suggestive of peptic ulcer disease, chronic pancreatitis, alcohol consumption or chronic liver disease. He was not on medications such as non-steroidal anti-inflammatory drugs or anti-coagulants. On examination, he was pale but there were no stigmata of chronic liver disease. His abdominal examination was normal except the digital examination of rectum revealing melaena stools. His haematological investigations including iron studies were suggestive of iron deficiency anaemia. The upper GI endoscopic examination showed mild antral gastritis. Colonoscopy was normal. Superior mesenteric artery angiogram showed abnormal serpiginous vessels in relation to the right colic artery. He was further investigated with capsule enteroscopy and contrast CT abdomen, but showed normal findings. Subsequently, he underwent extended right hemi-colectomy (Fig. ). The histology of the specimen showed abnormal vessels in the serosa and subserosa of the right colon.\nTwo weeks later he presented again with an episode of haematemesis and haematochezia. His full blood count showed a haemoglobin of 5.5 g/dl with microcytic hypochromic anaemia. Following resuscitation and stabilization, he underwent urgent upper GI endoscopy which revealed fresh bleeding from the ampulla of Vater.\nAn emergency laparotomy was done to control the bleeding. A duodenotomy was done and pulsatile bleeding from the ampulla of Vater was seen (Fig. ). On exploration, there was an abnormal tortuous vessel on the pancreatic head (Fig. ), which was originating from the coeliac trunk entering the head of the pancreas with several branches. Abnormal vessels were ligated and haemostasis was achieved (Fig. ). Post-operatively he also underwent angio-embolization of abnormal vessels originating from the coeliac trunk (Fig. ) and was discharged on post-operative day 14, but subsequently presented with an episode of massive upper GI and lower GI bleeding. Repeat angio-embolization failed due to difficulties in selective embolization of aberrant vessels in the pancreatic head region. Patient did not consent for a pancreatectomy and subsequently passed away due to massive GI bleeding.