ELECTRONIC IMAGE OF THE MONTH Intraductal Papillary Mucinous Neoplasm Presenting as Hemosuccus Pancreaticus Hiroyuki Inoue,* Masaki Katsurahara,‡ and Yoshiyuki Takei* *Department of Gastroenterology and Hepatology, ‡Department of Endoscopic Medicine, Mie University Graduate School of Medicine, Mie, Japan
78-year-old-man was admitted to our hospital complaining of melena for 10 days. He had been diagnosed with a cerebral infarction 3 years before admission and had been taking ticlopidine 200 mg twice daily since then. Laboratory tests showed mild anemia (hemoglobin level, 9.1 g/dL; reference range, 12–16 g/dL). His levels of serum amylase, carcinoembryonic antigen, and carbohydrate antigen 19-9 were within normal limits. An abdominal computed tomography showed a wellenhanced tumor in the dilated main pancreatic duct (Figure A), however, no extravasation of contrast medium was detected. An emergency upper gastrointestinal endoscopy was performed and fresh blood was seen to be oozing from the major papilla (Figure B). A subsequent endoscopic retrograde pancreatography showed bleeding from the dilated main pancreatic duct. Cytology of pancreatic juice showed no malignancy. Ticlopidine was stopped after endoscopy and the bleeding was self-limited. The suspicion of malignancy was high, and the patient underwent a distal pancreatectomy. The resected specimen confirmed diffuse dilatation of the main pancreatic duct, which was occupied by an intraductal tumor. Histologic examination showed that it was composed of tubular structures consisting of atypical, mucin-containing, columnar epithelial cells (Figure C). The tumor had spread to the branch duct and minimal invasion was observed. The hemorrhage site was located in the branch area of the tumor (Figure D). Tumor cells were focally positive for MUC2 and MUC5AC and the tumor was diagnosed as an intraductal papillary mucinous carcinoma with microinvasion. Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually resulting from a
A
pseudoaneurysm associated with acute or chronic pancreatitis.1 HP caused by a pancreatic tumor is extremely rare, only 4 cases have been reported previously.2–5 The pathologic diagnoses of these tumors were a metastatic pancreatic tumor of renal cell carcinoma, mucinous cystic neoplasm, carcinoma in situ of the pancreas, and pancreatic microcystic adenoma. Small-vessel wall failure caused by concomitant pancreatitis with tumor was suspected in the case of carcinoma in situ of the pancreas, and hemorrhage with tumor necrosis was suspected in the other 3 cases as the etiology of HP. In this case, we assumed that necrosis of hypervascular tumor epithelium in the pancreatic duct was the cause of HP. The ticlopidine also could have contributed to the bleeding, according to the pathologic findings and clinical course. We should keep intraductal papillary mucinous neoplasm of the pancreas in mind as a possible cause of HP in patients, especially those undergoing antiplatelet therapy.
References 1.
Kapoor S, Rao P, Sujoy P, et al. Hemosuccus pancreaticus: an uncommon cause of gastrointestinal hemorrhage: a case report. JOP 2004;5:373–376.
2.
Kurland J, Matthews T, Hoff E, et al. Hemosuccus pancreaticus caused by metastatic renal cell carcinoma. Gastrointest Endosc 2007;66:1241–1242.
3.
Shinzeki M, Hori Y, Fujino Y, et al. Mucinous cystic neoplasm of the pancreas presenting with hemosuccus pancreaticus: report of a case. Surg Today 2010;40:470–473.
Clinical Gastroenterology and Hepatology 2015;13:e57–e58
ELECTRONIC IMAGE OF THE MONTH, continued 4.
Inoue H, Katurahara M, Hamada Y, et al. Hemosuccus pancreaticus caused by in situ carcinoma of the pancreas. Endoscopy 2012;44:E336–E337.
5.
Shan YS, Sy ED, Tsai HM, et al. Chronic hemosuccus pancreaticus: a rare complication of pancreatic microcystic adenoma successfully treated with Whipple’s procedure. Pancreas 2000;20:416–418.
e58
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.12.013
78-year-old-man was admitted to our hospital complaining of melena for 10 days. He had been diagnosed with a cerebral infarction 3 years before admission and had been taking ticlopidine 200 mg twice daily since then. Laboratory tests showed mild anemia (hemoglobin level, 9.1 g/dL; reference range, 12–16 g/dL). His levels of serum amylase, carcinoembryonic antigen, and carbohydrate antigen 19-9 were within normal limits. An abdominal computed tomography showed a wellenhanced tumor in the dilated main pancreatic duct (Figure A), however, no extravasation of contrast medium was detected. An emergency upper gastrointestinal endoscopy was performed and fresh blood was seen to be oozing from the major papilla (Figure B). A subsequent endoscopic retrograde pancreatography showed bleeding from the dilated main pancreatic duct. Cytology of pancreatic juice showed no malignancy. Ticlopidine was stopped after endoscopy and the bleeding was self-limited. The suspicion of malignancy was high, and the patient underwent a distal pancreatectomy. The resected specimen confirmed diffuse dilatation of the main pancreatic duct, which was occupied by an intraductal tumor. Histologic examination showed that it was composed of tubular structures consisting of atypical, mucin-containing, columnar epithelial cells (Figure C). The tumor had spread to the branch duct and minimal invasion was observed. The hemorrhage site was located in the branch area of the tumor (Figure D). Tumor cells were focally positive for MUC2 and MUC5AC and the tumor was diagnosed as an intraductal papillary mucinous carcinoma with microinvasion. Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually resulting from a
A
pseudoaneurysm associated with acute or chronic pancreatitis.1 HP caused by a pancreatic tumor is extremely rare, only 4 cases have been reported previously.2–5 The pathologic diagnoses of these tumors were a metastatic pancreatic tumor of renal cell carcinoma, mucinous cystic neoplasm, carcinoma in situ of the pancreas, and pancreatic microcystic adenoma. Small-vessel wall failure caused by concomitant pancreatitis with tumor was suspected in the case of carcinoma in situ of the pancreas, and hemorrhage with tumor necrosis was suspected in the other 3 cases as the etiology of HP. In this case, we assumed that necrosis of hypervascular tumor epithelium in the pancreatic duct was the cause of HP. The ticlopidine also could have contributed to the bleeding, according to the pathologic findings and clinical course. We should keep intraductal papillary mucinous neoplasm of the pancreas in mind as a possible cause of HP in patients, especially those undergoing antiplatelet therapy.
References 1.
Kapoor S, Rao P, Sujoy P, et al. Hemosuccus pancreaticus: an uncommon cause of gastrointestinal hemorrhage: a case report. JOP 2004;5:373–376.
2.
Kurland J, Matthews T, Hoff E, et al. Hemosuccus pancreaticus caused by metastatic renal cell carcinoma. Gastrointest Endosc 2007;66:1241–1242.
3.
Shinzeki M, Hori Y, Fujino Y, et al. Mucinous cystic neoplasm of the pancreas presenting with hemosuccus pancreaticus: report of a case. Surg Today 2010;40:470–473.
Clinical Gastroenterology and Hepatology 2015;13:e57–e58
ELECTRONIC IMAGE OF THE MONTH, continued 4.
Inoue H, Katurahara M, Hamada Y, et al. Hemosuccus pancreaticus caused by in situ carcinoma of the pancreas. Endoscopy 2012;44:E336–E337.
5.
Shan YS, Sy ED, Tsai HM, et al. Chronic hemosuccus pancreaticus: a rare complication of pancreatic microcystic adenoma successfully treated with Whipple’s procedure. Pancreas 2000;20:416–418.
e58
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.12.013
