Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 5, 2003, pp. 441-442

Indian Journal of Surgery, Vol. 65, No. 5, Sept-Oct, 2003, pp. 441-442

Case Report

Massive ampullary bleed in chronic pancreatitis

M. R. Sreevathsa

Department of Surgery, M. S. Ramaiah Medical Teaching Hospital, New B.E.L. Road, Bangalore 560054.
Address for correspondence: Dr. M. R. Sreevathsa, Professor of Surgery, M. S. Ramaiah Medical Teaching Hospital, New B.E.L. Road, Bangalore 560054.

Paper Received: August 2002. Paper Accepted: November 2002. Source of Support: Nil.

How to cite this article: Sreevathsa MR. Massive ampullary bleed in chronic pancreatitis. Indian J Surg 2003;65:441-2.

Code Number: is03091

ABSTRACT

A 37-year-old alcoholic male patient presented with recurrent intractable upper gastrointestinal bleeding. The diagnosis was established by GI endoscopy and ERCP, as bleeding from the periampullary region. The clinical features, management and literature review are discussed here as such a presentation is extremely rare.

Key Words: Chronic pancreatitis, Gastrointestinal bleeding

INTRODUCION

Arterial complications due to chronic pancreatitis, leading to massive upper GI bleeding have been reported.^1,2 These patients present mainly as haematmesis and are managed by embolisation of the offending artery.^1-3 We report a patient with chronic pancreatitis presenting with massive bleeding from the ampullary lumen who underwent pancreatico-duodenectomy.

CASE REPORT

A 37-year-old man presented with epigastric pain of several years duration, aggravated since 18 months and associated with recurrent massive malena of 10 days duration. He occasionally used to pass frank blood per rectum. On physical examination a well-nourished young adult male, normotensive with no icterus was found to be extremely pale. Systemic examination was normal. Abdominal examination revealed epigastric tenderness with no organomegaly or free fluid. Haemoglobin was 6.9 gm % at admission and PCV 20%. Other biochemical investigations were within normal limits, with a serum albumin of 3.9 gm %. An upper GI endoscopy revealed bleeding from the ampullary lumen, and ERCP showed ductal irregularities with a diameter of 5 mm in the body. CT with contrast abdomen done to investigate for haemobilia showed no abnormalities.

The patient was managed conservatively for G.I. bleed. Inspite of it the patient had persistently low haemoglobin and also recurrent malena. Hence a surgical intervention was planned and preoperative coeliac axis and superior mesenteric artery angiography was done. The angiography was not contributory. Hence the patient was subjected to pancreatico-duodenectomy.

At surgery the pancreas was found to be firm with peripancreatic inflammation, and there was inflammatory oedema of the lesser omentum. The proximal small intestine contained dark coloured blood in the lumen on enterotomy. Enteroscopy showed no lesion in the small bowel distal to the duodenojejunal flexure. The patient had an uneventful recovery and his haemoglobin progressively increased up to 12.6 gm%, within 48 hours after surgery. Histopathological examination of the pancreatico-duodenectomy specimen showed features of chronic pancreatitis and periampullary vascular proliferation with intimal sclerosis and thrombosis of medium-sized vessels with no evidence of pseudocyst or aneurysm. The patient has been followed up for 3 years, and during this time he had no problems except niacin deficiency, which was treated.

DISCUSSION

To our knowledge, bleeding from pancreatic duct in the absence of a pseudoaneurysm is not reported in the literature. A case report of bleeding from the Wirsung's duct due to communication between the pancreatic and branch of the superior mesentric artery has been reported.⁴ Ampullary bleeding can arise from carcinoma of the ampulla or pancreatic injuries. The ampullary bleeding in our case was associated with chronic pancreatitis which did not show any vascular anomaly and hence angiography was not helpful. Ampullary pathology due to chronic pancreatitis should be considered when investigating a patient presenting with epigastric pain and history of alcoholism who presents with repeated upper gastrointestinal bleeding who at endoscopy is found not to have a definitive source in the stomach and small intestines. Definitive treatment in this setting would invariably involve a resectional procedure.

REFERENCES

1. Savastano S, Feltrin GP, Antonio T, Miotto D, Chiesura-Corona M, Castellan L. Arterial complications of pancreatitis: diagnostic and theraputic role of radiology. Pancreas 1993;8:687-92.
2. Huizinga WK, Baker LW. Surgical intervention for regional complications of chronic pancreatitis. Int Surg 1993;78:315-9.
3. Nogara MA, Cesar AM, Kanegusuku J, Lopes RW. Upper gastrointestinal hemorrhage associated with chronic pancreatitis and pseudocyst of a case. Arq Gastroenterol 1993;30:33-7.
4. Suter M. Hemorrhage through Wirsung's duct: rare form of upper gastrointestinal Hemorrhage. A case report. Helv Chir Acta 1993;60:91-5.

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