© Georg Thieme Verlag KG Stuttgart · New York
Hemosuccus pancreaticus after endoscopic ultrasound-guided fine needle aspiration of a pancreatic cyst
01 March 2010 (online)
A 71-year-old woman presented for endoscopic ultrasound (EUS) evaluation of a cystic lesion in the pancreas tail, which had been found on cross-sectional imaging during work-up of unintended weight loss. A 4.7 × 4.5 cm anechoic, septated macrocystic lesion was seen in the pancreas tail with a central calcification ([Fig. 1]). The remainder of the pancreas examination was normal. An avascular pathway was chosen and a 19-gauge needle was advanced into a large cystic component for fine needle aspiration (FNA). A frankly bloody aspirate was seen. Repeat EUS-FNA of a separate component of the cyst yielded slightly viscous, clear, nonbloody fluid, which was sent for analysis. The echoendoscope was then readvanced into the second portion of duodenum, demonstrating fresh blood emanating from the papilla ([Fig. 2]). With the echoendoscope in the second portion of the duodenum, endosonographic evaluation of the pancreatic duct revealed a hyperechoic filling defect consistent with blood ([Fig. 3]). The patient was admitted overnight for observation after developing mild, self-resolving pancreatitis, but she did not need further therapy. Histologic examination of the surgically resected cyst demonstrated a benign serous cystadenoma.
Fig. 1 Endoscopic ultrasound demonstrating a macrocystic pancreatic tail cyst with central calcification.
Fig. 2 A biopsy forceps was used to uncover the ampulla, with blood emanating from the papillary orifice.
Fig. 3 Endoscopic ultrasound of the pancreatic duct near the ampulla demonstrating a hyperechoic filling defect consistent with blood. This was not seen prior to cyst aspiration.
EUS-FNA is a procedure with a well-described low complication rate . Intracystic bleeding after EUS-FNA can occur, however, and rarely may result in hemosuccus pancreaticus  . A 19-gauge FNA needle was used for cyst aspiration in the present case, which may possibly contribute to this complication. In this case conservative management resulted in complete resolution.
- 1 Al-Haddad M, Wallace M B, Woodward T A. et al . The safety of fine-needle aspiration guided by endoscopic ultrasound: a prospective study. Endoscopy. 2008; 40 204-208
- 2 Singh P, Gelrud A, Schmulewitz N, Chauhan S. Hemosuccus pancreaticus after EUS-FNA of pancreatic cyst (with video). Gastrointest Endosc. 2008; 67 543
- 3 Bournet B, Migueres I, Delacroix M. et al . Early morbidity of endoscopic ultrasound: 13 years' experience at a referral center. Endoscopy. 2006; 38 349-354
R. N. Keswani, MD
Division of Gastroenterology, Department of Medicine, Northwestern University Feinberg School of Medicine
676 N. St. Clair Street