HEMOSUCCUS PANCREATICUS CAUSED BY AN PSEUDOANEURYSM OF THE PANCREATICODUODENAL ARTERY

João Fernandes^1,2, Sílvia Giestas¹, Tarcísio Araújo¹, José Ramada¹, David Martinez-Ares¹, Manuela Certo¹, Jorge Canena³, Luís Lopes^1,4,5

¹Gastroenterology Department, Hospital Santa Luzia, Viana do Castelo, Portugal; ²Gastroenterology Department, Centro Hospitalar Cova da Beira EPE, Covilhã, Portugal; ³Gastroenterology Department, Nova Medical School/Faculdade de Ciências Médicas de Lisboa; ⁴Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ⁵ICVS/3B’s – PT Government Associate Laboratory, Braga/Guimarães, Portugal

We present a 61-year-old man admitted with an acute pancreatitis and melena. Upper endoscopy revealed blood coming out of the major papilla. Abdominal ultrasound did not reveal stones in the gallbladder. An endoscopic ultrasound (EUS) was then performed. EUS assessment showed an heterogeneous pancreatic parenchima with multiple hypoechogenic areas and a dilated and tortuous Wirsung’s duct (6.5 mm at the neck). At the pancreatic head (unciform process), a 21X15mm cystic vascular lesion was revealed, with a turbulent arterial flow on doppler examination, suggestive of a pseudoaneurysm. CT confirmed the diagnosis. The patient was referred for endovascular treatment (posterior pancreatoduodenal artery), remaining asymptomatic after a 5 years of follow-up.

Hemosuccus pancreaticus or pseudohemobilia, is a rare but life-threatening cause of gastrointestinal bleeding. There are few cases of pseudoaneurysm of the pancreaticoduodenal artery diagnosed by EUS.

COMMON BILE DUCT MASS – AN UNEXPECTED DIAGNOSIS

Catarina Gouveia¹, Maria Pia Costa Santos¹, Catarina Fidalgo¹, Rui Loureiro¹, António Alberto Santos¹, Helena Oliveira², Rui Maio³, Marília Cravo¹

Serviços de ¹Gastrenterologia, ²Anatomia Patológica e ³Cirurgia Geral do Hospital Beatriz Ângelo

A 70-year-old woman presented with upper abdominal pain. Laboratory work up showed raised transaminases (AST 72UI/L, ALT 86UI/L), Ca 19.9 was normal. Upper GI endoscopy was normal, but abdominal CT scan showed common bile duct (CBD) dilation (22mm) with progressive straightening of the distal end. MRCP revealed a CBD dilation with stenosis 1cm above de papilla. Duodenoscopy showed a bulging papilla with normal mucosa. Ecoendoscopy revealed a CBD dilation (16mm) with a poorly defined hypoechogenic mass with 1.5×1.9cm, with no main pancreatic duct dilation, normal pancreatic parenchyma and no abnormal adenopathy. The case was discussed in a multidisciplinary meeting and surgery was decided due to the high probability of cholangiocarcinoma. The patient was submitted to a cephalic duodenopancreatectomy, which had no complications, with discharge at the 15th day of hospitalization. Pathological analysis was consistent with the diagnosis of CBD adenomyoma. Patient is well after 2.5 years of follow-up.

A PANCREATIC METASTASIS FROM PULMONARY ADENOCARCINOMA

Joana C. Branco, Gonçalo Alexandrino, Catarina G. Rodrigues, Jorge Reis

Serviço de Gastrenterologia do Hospital Professor Doutor Fernando Fonseca

A 65-year-old man with a recently diagnosed pulmonary adenocarcinoma was sent for evaluation by endoscopic ultrasound (EUS) for a pancreatic mass found on staging CT scan. On EUS a heterogeneous predominantly hypoechogenic mass in the pancreatic head, measuring 49x41mm, was identified (Figure 1). It didn’t conditioned significant Wirsung dilation. Elastography showed a hard pattern with a strain ratio of 75 (Figure 2). Multiple lymphadenopathies with malignant characteristics, located near the celiac trunk, hepatic hilum and peripancreatic were identified, the biggest measuring 26mm. Fine-needle aspiration (FNA) with a 25G needle in the pancreas (Figure 3) and with a 22G needle in a peripancreatic lymphadenopathy (Figure 4) were performed. Cytology examination was positive for adenocarcinoma and immunohistochemistry favored a pulmonary origin (CK7+,TTF1+,CDX2-,CK20-).

Pancreatic metastasis account for less than 5% of pancreatic tumors. FNA is crucial to the differential diagnosis since EUS appearance is very similar to primary tumors of the pancreas.