INTRODUCTION:Hemobilia refers to blood in the biliary tree and is a known cause of upper gastrointestinal bleeding. Bleeding into the pancreatic duct manifested by blood loss through the ampulla of Vater is known as Hemosuccus pancreaticus. It is often included under hemobilia though some authorities classify it as pseudohemobilia.
CASE PRESENTATION:A 74 year old female with history of diabetes and hypertension presented to an outside hospital complaining of one week of constant epigastric pain and non bilious non bloody emesis. There was no history of trauma or alcohol abuse. Laboratory parameters were notable for a lipase of 2922 U/L. Ultrasound and Computerized tomogram (CT) showed normal common bile duct and pancreatic inflammation with fluid collection in region of the tail. Conservative management for pancreatitis was instituted. On day three the patient developed massive upper GI bleeding, became hypotensive and required six units of packed red blood cells (PRBC) transfusions. Esophagogastroduodenoscopy (EGD) was normal. Repeat CT scan showed a mass in the region of the pancreatic head and body. The patient was transferred to our hospital for further management.Upon arrival, temperature was 99.9 °F, heart rate was 122 beats/minute, blood pressure was 163/80 mm Hg, respiratory rate was 28 breaths/minute and oxygen saturation was 99% on room air. Physical examination was remarkable only for mild epigastric tenderness. Hemoglobin was 8.4 gm/dL at time of transfer and dropped to 7.7 gm/dL despite four additional units of PRBC transfusion. Angiogram did not reveal the source of bleeding. A repeat EGD revealed blood coming from duct of Wirsung, confirming hemosuccus pancreaticus. Patient underwent urgent distal pancreatectomy. A large tumor mass was found in the body of the pancreas. Histology diagnosed infiltrating ductal adenocarcinoma in the distal pancreas.
DISCUSSIONS:Francis Glisson was the first to report hemobilia in 1654 in a young nobleman who was stabbed with a sword in the right upper quadrant and died due to massive gastrointestinal hemorrhage. The term “hemobilia” was first coined by Sandblom in 1948. Hemobilia can result from bleeding arising in the liver, extrahepatic bile ducts, gall bladder or pancreas. In the literature the liver is the most common site of bleeding and pancreas the least common. Hemobilia can be iatrogenic, or result from blunt or penetrating trauma, cholelithiasis, acalculous inflammatory diseases, neoplasm, parasitic infestations or vascular abnormalities. In 1871, Quincke described the classic triad of hemobilia - right upper quadrant pain, jaundice and upper gastrointestinal bleeding. The classic triad is present in only 22% of cases. Diagnosis of hemobilia depends on a high index of suspicion in patients with obscure GI bleeding. Diagnosis can be made by a combination of EGD, radiologic imaging and angiography. Most often, however, the diagnosis is made at surgery, which also provides an opportunity for definitive intervention. Other treatment options include conservative management, arterial embolization or percutaneous transhepatic biliary drainage procedures.
CONCLUSION:Though uncommon, hemobilia and hemosuccus pancreaticus should be considered in the differential diagnosis of obscure gastrointestinal bleeding. Exploratory surgery is the definitive modality, especially when conservative or minimally invasive interventions fail or if the diagnosis is uncertain.
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