• Acute pancreatitis
• Pancreatic disease
• Portal hypertension

• Humans
• Nomograms
• Male
• Female
• Retrospective Studies
• Middle Aged
• Pancreatitis/diagnosis
• Pancreatitis/complications
• Risk Factors
• Hypertension, Portal/diagnosis
• Hypertension, Portal/complications
• Adult
• Prognosis
• Tomography, X-Ray Computed
• Aged
• ROC Curve
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/etiology
• Predictive Value of Tests
• Acute Disease
• Body Mass Index

• National Natural Science Foundation of China - State Grid Corporation Joint Fund for Smart Grid
• National Key R&D Program of China

• Adverse events
• Chronic Pancreatitis
• Endoscopy
• Pancreatic extracorporeal shock wave lithotripsy
• Pancreatic stones

• Humans
• Pancreatic Diseases/therapy
• Pancreatic Diseases/etiology
• Pancreatic Ducts
• Treatment Outcome
• Lithotripsy/adverse effects
• Lithotripsy/methods
• Calculi/therapy

• 82070664 National Natural Science Foundation of China
• 19DZ2201900 Shanghai Science and Technology Innovation Action Plan
• 20SG36 Shanghai Shuguang Program

• Hemorrage of pancreatic duct
• embolization
• pseudoaneurysm
• super-selective

• Humans
• Aneurysm, False/complications
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/surgery
• Pancreatic Diseases/etiology
• Pancreatic Diseases/surgery
• Pancreatic Ducts/surgery
• Treatment Outcome

Hemosuccus pancreaticus is a life-threatening but rare cause of intermittent upper gastrointestinal bleeding caused by acute/subacute hemorrhage into a pancreatic duct or pancreatic pseudocyst because of a ruptured pseudoaneurysm. This entity is described in patients with pseudoaneurysms that develop in the context of severe pancreatic/peripancreatic inflammatory changes. Hemosuccus pancreaticus presents a difficult diagnostic and therapeutic conundrum because it tends to involve inflamed, friable, and tortuous vascular pathways. We present a rare case of hemosuccus pancreaticus because of splenic pseudoaneurysm presenting as duodenal hemorrhage and discuss trans-splenic embolization with a combined angiographic and ultrasound-guided approach.

Pseudoaneurysms of the pancreatic and peripancreatic arteries is a well-known complication of chronic or necrotizing pancreatitis due to proteolytic enzymatic digestion of the arterial wall. A major part of peripancreatic pseudoaneurysms involve the splenic artery, but any peripancreatic artery may be involved and bleed. They are potentially life threatening for patients, due to spontaneous intraperitoneal rupture, rupture and fistulization into the surrounding organs, or fistulization into the pancreatic duct. Small ones are usually asymptomatic and are often diagnosed incidentally, while giant (> 5 cm) aneurysms and pseudoaneurysms are symptomatic and may be detected as a pulsatile mass in the upper-left quadrant or epigastrium. Imaging plays a key role in the identification of splenic artery aneurysms and pseudoaneurysms, while angiography still represents the gold standard for the diagnosis, although nowadays it plays a prominent role in treatment. Treatment of splenic artery pseudoaneurysms is mandatory because of the high probability of rupture, with a mortality rate of up to 90%. The gold standard treatment is represented by surgery, with a mortality rate between 16% and 50%. In recent years the endovascular approach has proven to be an effective alternative treatment for splenic artery pseudoaneurysms, and it is currently the method of choice. In this article, we present the case of a ant pseudoaneurysm of the splenic artery due to huge pseudocysts in a young alcoholic patient with recurrent and chronic pancreatitis, complicated by fistulization and invasion of spleen parenchyma and arteriovenous fistula.

• chronic pancreatitis
• endovascular embolization
• pseudoaneurysm
• splenic artery

• IPMN
• anticoagulation drug
• hemosuccus pancreaticus
• pseudoaneurysm

• Acute Disease
• Aged
• Aneurysm, False/complications
• Aneurysm, False/diagnostic imaging
• Angiography
• Female
• Humans
• Pancreatic Neoplasms/complications
• Pancreatitis

The pancreas is an unusual source of gastrointestinal (GI) bleeding. GI bleeding from the pancreas is most frequently a result of complications from acute or chronic pancreatitis resulting in vascular damage and bleeding into the pancreatic duct. Rarely, however, a pancreatic pseudocyst can come into contact with the GI tract and form a fistula. However, these fistulas can be difficult to identify during endoscopy due to their lateral position, and computed tomography is often necessary to make a definitive diagnosis. Erosion of the nearby vasculature as a result of the fistula can lead to bleeding. Embolization of the affected vessel is the standard of care, but particular attention should be given to not empirically embolize due to risk of complications. Here, we describe a case of an upper GI bleed due to a pancreatic pseudocyst that fistulized through the duodenal wall.

• fistula
• gastrointestinal bleeding
• pancreatic pseudocyst
• pancreatitis

Pseudoaneurysms (PAs) caused by traumatic injury to the arterial vasculature have a high risk of rupture, leading to life-threatening hemorrhage and mortality, requiring urgent treatment. The purpose of this study was to determine the technical and clinical outcomes of endovascular treatment of visceral and extremity traumatic pseudoaneurysms.

Clinical data were retrospectively collected from all patients presenting for endovascular treatment of PAs between September 2012 and September 2018 at a single academic level one trauma center. Technical success was defined as successful treatment of the PA with no residual filling on post-embolization angiogram. Clinical success was defined as technical successful treatment with no rebleeding throughout the follow-up period and no reintervention for the PA.

Thirty-five patients (10F/25M), average age (± stdev) 41.7 ± 20.1 years, presented with PAs secondary to blunt (n = 31) or penetrating (n = 4) trauma. Time from trauma to intervention ranged from 2 h - 75 days (median: 4.4 h, IQR: 3.5–17.1 h) with 27 (77%) of PAs identified and treated within 24 h of trauma. Average hospitalization was 13.78 ± 13.4 days. Ten patients underwent surgery prior to intervention. PA number per patient ranged from 1 to 5 (multiple diffuse). PAs were located on the splenic (n = 12, 34.3%), pelvic (n = 11, 31.4%), hepatic (n = 9, 25.7%), upper extremity/axilla (n = 2, 5.7%), and renal arteries (n = 1, 2.9%). Technical success was 85.7%. Clinical success was 71.4%, for technical failure (n = 5), repeat embolization (n = 1) or post-IR surgical intervention (n = 4). There was no PA rebleeding or reintervention for any patient after discharge over the reported follow-up periods. Three patients died during the trauma hospitalization for reasons unrelated to the PAs.

Endovascular treatment of traumatic visceral and extremity PAs is efficacious with minimal complication rates and low reintervention requirements.

• Endovascular treatment
• Pseudoaneurysm
• Trauma

Pancreatic pseudocyst is a common complication of pancreatitis. Pseudocysts may require decompression when they become painful, infected, or start compressing surrounding organs. Decompression is achieved by endoscopic cystogastrostomy. Recently, the use of lumen-apposing metal stent (LAMS) for cystogastrostomy has gained popularity due to ease of use and high technical success. LAMS has a wider lumen, which allows for direct endoscopic necrosectomy in the cases of walled-off necrosis. Our patient is a 30-year-old male who presented with massive hematemesis and dizziness. He had a history of chronic alcohol-induced pancreatitis. Three weeks before the presentation, he underwent a cystogastrostomy with LAMS placement to treat a 10-cm walled-off necrosis. Urgent computed tomography (CT) scan did not reveal any acute finding suggestive of bleeding. Esophagogastroduodenoscopy showed blood protruding from the LAMS with a large clot formation. Attempts to stop bleeding were unsuccessful. He underwent CT angiography of the abdomen. CT angiography showed a bleeding pseudoaneurysm (PA) believed to be a complication of the LAMS. Subsequently, multiple coils were placed in the splenic artery near the PA. The patient continued to improve without a further drop in hemoglobin and was eventually discharged. PA formation and subsequent rupture is a rare delayed complication of LAMS. It may lead to massive gastrointestinal bleeding with a high mortality rate. Diagnostic delays have resulted in increased mortality by 60%. In this article, we present a case of massive gastrointestinal bleeding due to a ruptured splenic artery PA presenting as a delayed complication of LAMS.

• complication of AXIOS stent
• pancreatic fluid collection
• ruptured pseudoaneurysm

This study aimed to assess the prevalence, clinical characteristics, and risk factors for sinistral portal hypertension in patients with moderate or severe acute pancreatitis.

A retrospective study included 825 patients with moderate or severe acute pancreatitis. Clinical and demographic data, the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Ranson scores for severity of acute pancreatitis, and the computed tomography (CT) severity index (CTSI) were evaluated. The formation of collateral vessels, bleeding, splenomegaly, hypersplenism during hospitalization or follow-up, and early anticoagulation and the occurrence of sinistral portal hypertension were evaluated.

Of the 825 patients with moderate or severe acute pancreatitis, 103 patients (12.5%) developed sinistral portal hypertension. The median time to diagnosis was 8 months, and the median patient age was 39 years. The most common causes of pancreatitis were biliary (46.3%), hypertriglyceridemia (31.5%), alcohol (14.9%), and others (7.3%). Independent risk factors for sinistral portal hypertension were male gender (OR, 4.666; 95% CI, 2.54–8.572; P<0.001), recurrent acute pancreatitis (OR, 9.556; 95% CI, 5.218–17.5; P<0.001), hypertriglyceridemia (OR, 2.056; 95% CI, 1.184–3.57; P=0.001), glucose >10 mmol/L (OR, 6.965; 95% CI, 4.027–12.045; P<0.001), smoking (OR, 6.32; 95% CI, 3.544–11.269; P<0.001), and infection of walled-off necrosis (OR=1.637; 95% CI, 1.061–2.524; P=0.015). Anticoagulation during hospitalization was not significantly associated with sinistral portal hypertension.

Hypertriglyceridemia, hyperglycemia, infection of walled-off necrosis, recurrent acute pancreatitis, and smoking were risk factors for sinistral portal hypertension, and early anticoagulation did not prevent the occurrence.

Duodenal duplication cysts in adults are rare, and a preoperative diagnosis remains difficult because clinical manifestations are nonspecific and variable. We describe a case of a duodenal duplication cyst mimicking a pancreatic pseudocyst with repeated intracystic hemorrhage.

A 47-year-old male who complained of upper abdominal pain and vomiting was referred to our hospital. He was a heavy drinker and had a past history of hospitalization for alcoholic chronic pancreatitis. Plain abdominal computed tomography (CT) showed a cystic lesion of 7 cm in size in the lumen near the second part of the duodenum. The cystic lesion showed high density inside. Gastrointestinal endoscopy revealed that the lumen of the duodenum was deformed by a submucosal tumor-like mass and the endoscope could not pass through it, but active bleeding was not seen in the lumen of the duodenum. On the fourth day of hospitalization, anemia progressed and contrast-enhanced CT demonstrated a high-density spot on the wall of the cystic lesion. A pancreatic pseudocyst complicated with intracystic hemorrhage was preliminarily considered. Angiography was immediately performed, and a pseudoaneurysm was identified in the branch of the anterior superior pancreaticoduodenal artery (ASPDA). Transcatheter arterial embolization (TAE) was performed. Anemia did not progress after that, and follow-up CT showed reduction in the size of the cystic lesion. Afterward, the same symptoms recurred twice and surgical treatment was performed for the pancreatic pseudocyst with repeated intracystic hemorrhage. Macroscopically, a cystic mass of 5 cm in size was adjacent to the second part of the duodenum on the pancreas side. A pinhole-sized communication was identified between the cyst and the duodenum lumen. Microscopically, the cyst wall was composed of gastric mucosa and shared a common proper muscle layer with the duodenum. Chronic ulcers and erosions were seen in the cyst. Based on these findings, a diagnosis of duodenal duplication cyst was made.

Duodenal duplication cysts in adults have seldom been reported and should be considered as a differential diagnosis for a patient with a cystic lesion adjoining the duodenum.

• Duodenum duplication cyst
• Intracystic hemorrhage
• Pancreatic pseudocyst

Hemosuccus pancreaticus is a very rare cause of gastrointestinal bleeding and can be life-threatening if not managed appropriately. Still thought to be a surgical problem, advances in medical therapy now afford these patients the opportunity to undergo less-invasive angiography techniques to manage this illness when it occurs. Here, we present a case of hemosuccus pancreaticus safely managed with liquid N-butyl-2-cyanoacrylate embolization.

• Chronic
• Embolization
• Hemosuccus
• Pancreatitis
• Pseudoaneurysm
• Thrombin

• Cystogastrostomy
• Laparoscopy
• Pancreatic pseudocysts
• Pancreatitis

• GI bleed
• iliacal–duodenal fistula
• peripheral arterial pseudoaneurysm
• splanchnic pseudoaneurysm

• Aged
• Aneurysm/surgery
• Aneurysm, False/diagnostic imaging
• Aneurysm, False/therapy
• Aortic Aneurysm, Abdominal/diagnostic imaging
• Aortic Aneurysm, Abdominal/therapy
• Catheterization
• Embolization, Therapeutic
• Female
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Retrospective Studies
• Time
• Tomography, X-Ray Computed
• Treatment Outcome
• Vascular Surgical Procedures
• Viscera/blood supply

• Administration, Cutaneous
• Adult
• Aneurysm, False/complications
• Aneurysm, False/therapy
• Cholangiopancreatography, Endoscopic Retrograde
• Drainage/methods
• Endoscopy
• Humans
• Male
• Pancreatic Pseudocyst/etiology
• Pancreatic Pseudocyst/therapy
• Retrospective Studies
• Thrombin/administration & dosage
• Treatment Outcome

Background. Hemosuccus pancreaticus (HP) is a very rare and obscure cause of upper gastrointestinal bleeding. Due to its rarity, the diagnostic and therapeutic strategy for the management of this potentially life threatening problem remains undefined. The objective of our study is to highlight the challenges in the diagnosis and management of HP and to formulate a protocol to effectively and safely manage this condition. Methods. We retrospectively reviewed the records of all patients who presented with HP over the last 15 years at our institution between January 1997 and December 2011. Results. There were a total of 51 patients with a mean age of 32 years. Nineteen patients had chronic alcoholic pancreatitis; twenty-six, five, and one patient had tropical pancreatitis, acute pancreatitis, and idiopathic pancreatitis, respectively. Six patients were managed conservatively. Selective arterial embolization was attempted in 40 of 45 (89%) patients and was successful in 29 of the 40 (72.5%). 16 of 51 (31.4%) patients required surgery. Overall mortality was 7.8%. Length of followup ranged from 6 months to 15 years. Conclusions. Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. All hemodynamically stable patients with HP should undergo prompt initial angiographic evaluation, and if possible, embolization. Hemodynamically unstable patients and those following unsuccessful embolization should undergo emergency haemostatic surgery. Centralization of GI bleed services along with a multidisciplinary team approach and a well-defined management protocol is essential to reduce the mortality and morbidity of this condition.

Endoscopic ultrasonography (EUS) was performed on a patient being treated for chronic pancreatitis because a submucosal tumor was observed in the stomach during gastrointestinal endoscopy. As internal pulsatile blood flow on Doppler was present, the diagnosis of an aneurysm was made. The pseudoaneurysm of the left gastric artery was embolized with histoacryl and lipiodol and the splenic artery was embolized with coils at the location of the pseudoaneurysm to prevent hemorrhage. Follow up EUS confirmed the cessation of blood flow from the pseudoaneurysm. Clinicians encountering a gastric submucosal tumor-like protrusion in a patient with chronic pancreatitis should use EUS to investigate the possibility of a pseudoaneurysm, which must be treated as quickly as possible once identified.

• Chronic pancreatitis
• Endoscopic ultrasonography
• Pseudoaneurysm

Pancreatic pseudoaneurysm is a rare vascular complication of chronic pancreatitis resulting from erosion of the pancreatic or peripancreatic artery into a pseudocyst that is identified as a pulsating vascular malformation which may lead to lethal complications if left untreated. Many publications in the literature consider angiography as the first step in the management of pancreatic pseudoaneurysm to stabilize the patient's critical condition; it should be followed by surgical intervention as the definite treatment. We report a rare case of pancreatic pseudoaneurysm rupture with hemodynamic embarrassment in a critical patient with multiple comorbid conditions and poor risk for surgery who responded dramatically to angiographic management as a single therapeutic modality without further surgical intervention. The results observed in our patient suggest that pancreatic pseudoaneurysm may be successfully managed with angiography only and that not all cases require surgical intervention. This is particularly relevant in critically ill patients in whom surgical intervention would be unfeasible.

• Angiography
• Arterial embolization
• Pancreatitis
• Pseudoaneurysm

• Angiography
• chronic pancreatitis
• embolization
• interventional radiology
• pseudoaneurysm

• Angiography
• chronic pancreatitis
• embolization
• interventional radiology
• pseudoaneurysm

• Aneurysm, False/etiology
• Aneurysm, False/therapy
• Arteries
• Duodenum/blood supply
• Embolization, Therapeutic/methods
• Humans
• Male
• Middle Aged
• Pancreatitis, Chronic/complications
• Stomach/blood supply

• Aneurysm, False/therapy
• Duodenum/blood supply
• Embolization, Therapeutic/methods
• Enbucrilate/administration & dosage
• Epinephrine/administration & dosage
• Ethiodized Oil/administration & dosage
• Fluoroscopy
• Humans
• Male
• Middle Aged
• Pancreas/blood supply
• Pancreatitis/therapy
• Splenic Artery
• Tomography, X-Ray Computed
• Treatment Outcome
• Vasoconstrictor Agents/administration & dosage

Cystic lesions in a variety of organs are being increasingly recognized as an incidental finding on cross-sectional imaging. These lesions can be benign, premalignant or malignant. When these cystic lesions are small it can be difficult to characterize them radiologically. However, with appropriate clinical history and knowledge of typical imaging features of cystic pancreatic lesions this can enable accurate diagnosis and thus guide appropriate treatment. In this review, we provide an overview of the most common types of cystic lesions and their appearance on computer tomography, magnetic resonance imaging and ultrasound. We will also discuss the follow up and management strategies of these cystic lesions.

• Cystic pancreatic lesions
• Follow up management
• Imaging

We present a 61-year-old woman with hypovolemic shock due to a ruptured aneurysm of the superior posterior pancreatic-duodenal artery in whom recurrent syncopes were the first presenting sign of pancreatic-duodenal artery aneurysm (PDAA). PDAA is a rare but life-threatening condition. The widely varying symptomatology may lead to a delay in diagnosis and treatment. Patients with atypical symptoms, such as vague abdominal pain, recurrent dizziness or syncope, may actually suffer from a sentinel bleeding of the vascular malformation. Radiological imaging, especially selective angiography, may provide a diagnostic as well as a therapeutic tool in these patients.

• chronic pancreatitis
• haemosuccus pancreaticus
• upper gastrointestinal bleeding