The wirsungorrhagies: Causes and management in 14 patients

Background and Study Aims: Wirsungorrhagy is an extremely rare cause of upper gastrointestinal bleeding. The present study describes 14 cases observed over a seven-year period. Material and Methods: Among 10,000 endoscopic retrograde cholangiopancreatographies performed between 1989 and 1996 we have identified 14 wirsungorrhagies, which were reviewed retrospectively. They occurred in patients with chronic and acute pancreatitis, and primary and metastatic pancreatic cancer. Results: Clinical signs of bleeding were present in six patients; three other patients had occult blood loss, and in five patients wirsungorrhagy was caused by endoscopic manipulation (n = 3) or extracorporeal shock-wave lithotripsy (n = 2) without clinical or hemodynamic effects. In six patients, wirsungorrhagy was managed by endoscopic methods. Five patients in unstable clinical conditions had an arteriography which allowed identification and treatment of the source of bleeding in three cases. Two patients with bleeding from a communicating cyst in chronic pancreatitis underwent surgery. Conclusions: Wirsungorrhagy can be responsible for massive bleeding in certain patients, especially those with chronic pancreatitis and pseudoaneurysm. In these cases, arteriography is most useful for identification and treatment of the bleeding. When it occurs during endoscopic manipulations, it can usually be managed endoscopically and/or stops spontaneously with appropriate main pancreatic duct drainage. When it occurs in patients with pancreatic tumors, optimal treatment is surgical resection; this is, unfortunately, usually not feasible.