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it is described as bleeding from the ampulla of vater where blood comes via the pancreatic duct .
it is a rare cause of intermittent upper gastrointestinal ( gi ) bleeding which occurs in 1:1500 cases of gi bleeding .
it was first reported in 1931 by lower and farrell   who reported bleeding from an aneurysm of the splenic artery coming via the pancreatic duct and the ampulla of vater . to date , about 125 cases have been reported in the literature . here ,
we report the first case of hp due to aberrant vessels from the coeliac trunk and the difficulties faced in the management .
a 63-year - old male who had been investigated for iron deficiency anaemia of 1 year duration presented with repeated bouts of melaena .
he did not give a past history suggestive of peptic ulcer disease , chronic pancreatitis , alcohol consumption or chronic liver disease .
he was not on medications such as non - steroidal anti - inflammatory drugs or anti - coagulants . on examination
superior mesenteric artery angiogram showed abnormal serpiginous vessels in relation to the right colic artery .
he was further investigated with capsule enteroscopy and contrast ct abdomen , but showed normal findings .
subsequently , he underwent extended right hemi - colectomy ( fig .  1 ) .
the histology of the specimen showed abnormal vessels in the serosa and subserosa of the right colon . 

his full blood count showed a haemoglobin of 5.5 g / dl with microcytic hypochromic anaemia . following resuscitation and stabilization
, he underwent urgent upper gi endoscopy which revealed fresh bleeding from the ampulla of vater .
a duodenotomy was done and pulsatile bleeding from the ampulla of vater was seen ( fig .  2 ) . on exploration
3 ) , which was originating from the coeliac trunk entering the head of the pancreas with several branches .
post - operatively he also underwent angio - embolization of abnormal vessels originating from the coeliac trunk ( fig .  5 ) and was discharged on post - operative day 14 , but subsequently presented with an episode of massive upper gi and lower gi bleeding .
repeat angio - embolization failed due to difficulties in selective embolization of aberrant vessels in the pancreatic head region .
patient did not consent for a pancreatectomy and subsequently passed away due to massive gi bleeding . 
 figure  2:arterial blood spurting from the major duodenal papilla
hp is most commonly caused by a rupture of an aneurysm of the splenic artery associated with acute or chronic pancreatitis .
pseudoaneurysms of the hepatic , gastroduodenal and pancreaticoduodenal arteries have also been reported as sources of bleeding [ 2 , 3 ] .
pancreatolithiasis , pseudocyst of the pancreas , trauma and rupture of primary splenic aneurysms have been identified as other uncommon causes [ 47 ] . according to vimalaraj
et al . , in a case series of 31 hp patients , they had identified the bleeding source arising from the splenic artery ( n = 17 ) , gastroduodenal artery ( n = 5 ) , superior pancreaticoduodenal artery ( n = 1 ) , inferior pancreaticoduodenal artery ( n = 2 ) and from the superior mesenteric artery ( n = 1 ) .
however , our patient had a different mechanism due to abnormal feeding vessels feeding the pancreatic head from the coeliac trunk .
it was difficult to make the diagnosis of hp because of intermittent haemorrhage from a source that was not readily visualized by endoscopy . according to the previous authors
, the management for hp should be aimed at eradicating the source of bleeding completely .
there are two choices for the treatment of hp : ( i ) surgery ( e.g. resection of the pancreas head or tail ) and ( ii ) radiological embolization .
if the source of haemorrhage is found by arteriography , interventional radiological therapy should be done . recently ,
benz et al .   reported the interventional radiological therapy of hp by implantation of an uncoated metal palmaz stent across the aneurysmal segment of splenic artery .
for the patient with hp who has a pancreatic disease such as pancreatic pseudocyst , surgical treatment may be appropriate .
however , our patient did not show any clinical or radiological features suggestive of pancreatitis . at the time of acute bleeding
therefore , the only option for control of bleeding was emergency surgery which was successful at the time and followed by angio - embolization using gelform .
intraoperative ultrasonography is useful to confirm the origin of haemorrhage , but in our setting , we did not have facilities for intraoperative ultrasonography .
conservative surgery by ligature of the pancreatic ducts has been used , but the results are unsatisfactory because the causal lesion remains intact .
arterial ligation is also effective , but it does not avoid the risk of recurrence .
therefore , we planned for a pancreatic resection , but the patient did not consent for this procedure . in conclusion , there are several lessons to be learnt from this rare case . in evaluating patients with recurrent obscure gi bleeding ,
it is important always to remember that the pancreas is a part of the upper gi tract which is prone to be the source of haemorrhage . also it could be a diagnostic challenge even to an expert in gi endoscopy to diagnose this condition unless there is active bleeding from the papilla at the time of endoscopy .
haemosuccus pancreaticus ( hp ) is a rare life - threatening cause of intermittent upper gastrointestinal bleeding . 
 we report the first documented case of hp due to bleeding from aberrant vessels originating from the coeliac trunk feeding the head of the pancreas . 
 our patient underwent initial surgery and subsequent angio - embolization . 
 this case report describes the challenges faced during the diagnosis and treatment .