Management of Bleeding from the Pancreas
Acute hemorrhage originating from the pancreas is the least common form of gastrointestinal bleeding. Patients typically present with a triad of epigastric abdominal pain, intermittent gastrointestinal hemorrhage, and hyperamylasemia. Diagnosis is challen
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Management of Bleeding from the Pancreas Scott Dolejs and Eugene P. Ceppa
Introduction Acute hemorrhage originating from the pancreas is the least common form of upper gastrointestinal bleed [1, 2]. Specifically, hemorrhage from the pancreatic duct through the papilla of Vater is rare with approximately 200 cases having been reported in the literature. The first report by Lower and Farrell in 1931 identified a splenic artery aneurysm as the cause [3]. This phenomenon has been described in various terms including wirsungorrhagia and hemowirsungia, highlighting the identification of hemorrhage from the pancreatic duct into the duodenum [4–7]. Hemosuccus pancreaticus was first proposed by Sandblom in 1970 signifying emission of blood from the pancreatic duct through the ampulla of Vater [8]. Longmire proposed hemoductal pancreatitis as another synonymous term [9].
Surgical Anatomy Eristratos first described the pancreas in 300 BC. The origin of the word pancreas is Greek for pan meaning all and kreas defined as meat/flesh. The pancreas is a retroperitoneal organ situated at the level of the L2 vertebrae. The pancreas is commonly divided into segments consisting of the head, uncinate process, neck, body, and tail. The head of the pancreas lies nestled in the c-loop of the duodenum and the uncinate process is the portion of the head that extends posterior to the superior mesenteric vessels. The neck overlies the superior mesenteric vessels. The body begins at the level of the superior mesenteric vessels and the tail extends into the splenic hilum.
S. Dolejs, M.D. • E.P. Ceppa, M.D. (*) Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA e-mail: [email protected] © Springer International Publishing AG 2016 A.D. Pryor et al. (eds.), Gastrointestinal Bleeding, DOI 10.1007/978-3-319-40646-6_10
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S. Dolejs and E.P. Ceppa
The duct of Wirsung (main pancreatic duct) was first described in 1642 and the duct of Santorini (accessory duct) in 1734. These are the two main ducts that drain exocrine secretions into the duodenum. The duct of Wirsung drains most of the head, body, and tail of the pancreas, while the duct of Santorini drains the superior portion of the head. Most possess branching that connects these two major ducts. Vater described the common bile duct and ampulla in 1720. However, it was not until 1919 that a pathologist from Johns Hopkins by the name of Oddi described the common duct theory where the common bile duct and main pancreatic duct joined together to drain via the ampulla of Vater into the duodenum. Of note, the accessory duct empties directly into the duodenum (minor papilla) several centimeters proximal to the ampulla of Vater. The arterial blood supply of the pancreas is both redundant and profound. The celiac axis provides the common hepatic artery which in turn supplies the gastroduodenal artery as the origin of the superior branches of the pancreaticoduodenal artery. The pancreaticoduodenal branches supply the head of the pancreas. In addition the splenic artery prov
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