一例罕見原因的消化道出血！
撰文| 陳徐佳
急診科來了一個患者，臉色蒼白，此前曾大量飲酒，怎麼回事？
病例摘要
■現病史
患者，男性，46歲，有酒精濫用史，先前曾患急性胰腺炎，併發急性肺栓塞予抗凝治療。3周前大量飲酒後表現為深度疲乏，急診入院。
■體格檢查
皮膚黏膜蒼白，腹部柔軟，觸診無觸痛。
■實驗室檢查
血紅蛋白為29g/L，紅細胞壓積（HCV）為11.9%，平均紅細胞體積（MCV）為71.7fL，血小板計數為557k/μL。血生化指標顯示低鈉血癥，鈉含量為126mmol/L，尿素氮為3.56mmol/L，肌酐為60μmol/L。除此之外，患者的實驗室檢查均在正常範圍內。患者一年前基線血紅蛋白為172g/L。無嘔血、黑便或便血的證據。
■影像學檢查
食管胃十二指腸鏡檢查（EGD）顯示（洛杉磯分型D級），Vater乳頭區域有血跡（圖A），但無明顯出血。CT血管造影見圖B，EGD顯示乳頭區域有血跡，進一步行內鏡逆行胰膽管造影（ERCP）和內鏡下胰膽管造影（EUS）檢查，沒有進一步的證據提示胰腺出血。
患者進一步接受了CT血管造影，除了胃十二指腸動脈假性動脈瘤（gastroduodenal artery pseudoaneurysm，GDA）外，還顯示了一個非特徵性的胰腺腫塊，胰腺腫塊的特徵是良性囊性改變，結合ERCP、EUS可能與他先前的急性胰腺炎發作有關。
圖A
圖B
Q
結合以上資訊，你認為最有可能的診斷是？後續如何處理呢？
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參考文獻：
[1] Duarte C, Li N, Blood in the Duodenum, Gastroenterology (2019), doi: https://doi.org/10.1053/j.gastro.2019.10.049.
[2] Etienne S, Pessaux P, Tuech JJet al. Hemosuccus pancreaticus: A rare cause of gastrointestinal bleeding. Gastroenterol Clin Biol, 2005; 29:237-242.
[3] Han B, Song ZF, Sun B: Hemosuccus pancreaticus: A rare cause of gastrointestinal bleeding. Hepatobiliary Pancreat Dis Int, 2012; 11(5):479-488.
[4] Ru N, Zou WB, Qian YY, et al. A Systematic Review of the Etiology, Diagnosis, and Treatment of Hemosuccus Pancreaticus. Pancreas. 2019;48(5):e47-e49.
[5] Inayat F, Ali N, Khan M, et al.: Hemosuccus Pancreaticus: A Great Masquerader inPatients with Upper Gastrointestinal Bleeding. Cureus, 2018; 10(12):e3785.
[6] Maheshwaran MU, Sathyanesan J, Ramasamy S.Hemosuccuspancreaticus: 18-year experience from a ter-tiary care GI bleed centre in India. HPB, 2016; 18:784.
[7] Lower WE, Farrell JI: Aneurysm of the splenic artery: Report of a case and review of the literature. Arch Surg, 1931; 23:182-190.
[8] Jin S, Dong X, Ping C: Image of the month. Pancreaticoduodenal artery and superior mesenteric artery pseudoaneurysm associated with hemosuccus pancreaticus. Clin Gastroenterol Hepatol, 2010; 8:11-12.
[9] Rammohan A, Palaniappan R, Ramaswami S: Hemosuccus Pancreaticus: 15-Year Experience from a Tertiary Care GI Bleed Centre. ISRN Radiology, 2013; 191-194.
[10] Baiocch GL, Piardi T, Cuomo R,et al. Trattamento endovascolare di pseudoaneurisma rotto dell’arteria gastroduodenale in esiti di pancreatite acuta. Ann Ital Chir, 2007; 78(2), 145-148.
[11] Gambiez LP, Ernst OJ, et al.: Arterial embolization for bleeding pseudocystscomplicating chronic pancreatitis. Arch Surg, 1997; 132: 1016–21
[12] Lermite E, Regenet N, Tuech JJ et al. Diagnosis and treatment of hemosuccuspancreaticus: development of endovascular management. Pancreas, 2007; 34:229-232
[13] Yu P, Gong J: Hemosuccus pancreaticus: A mini-review. Ann Med Surg (Lond), 2018; 28:45-54.
[14] Suter M, Doenz F, Chapuis G, Gillet M, Sandblom P. Haemorrhage into the pancreatic duct (Hemosuccus pancreaticus): recognition and management. The European journal of surgery = Acta chirurgica. 1995;161(12):887-892.
[15]Zyromski NJ, Vieira C, et al.: Improved outcomes in postopera-tive and pancreatitis-related visceral pseudoaneurysms. J Gastrointest Surg, 2007; 11:50-55.
[16] Sethi H, Peddu P, Prachalias A, Kane P, Karani J, Rela M, et al.: Selective embolization for bleeding visceral artery pseudoaneurysms in patients with pancreatitis. Hepatobiliary Pancreat Dis Int, 2010;9:634-38
[17] Vimalraj V, Kannan DG, Sukumar R, et al.: Haemosuccuspan-creaticus: Diagnostic and therapeutic challenges. HPB, 2009; 11(4)4:345-50.
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