A 70-year-old male presented to our medical center with one episode of “black tarry stools” in the morning. Three weeks prior to this admission, the patient underwent esophagogastroduodenoscopy (EGD), which revealed a 6-mm, clean-based ulcer at the gastroesophageal junction without active bleeding. Colonoscopy, performed during the same visit, was significant for mild diverticulosis and small nonbleeding hemorrhoids. He had a medical history of chronic active alcohol abuse, prior gastrointestinal bleeding, hypertension, diabetes mellitus type 2, and non-small-cell lung cancer (T2N0M0; status post-lobectomy, 18 years ago). The patient had been consuming 3-4 drinks of liquor daily; however, he was non-smoker and drug-free. He was under therapy with oral iron sulfate, metformin, pantoprazole, enalapril, and multivitamins. Review of the systems was significant for fatigue, malaise, and confusion. His vitals included blood pressure 137/81 mm Hg, heart rate 108 beats per minute, temperature 36.9°C, respiratory rate 16 per minute and oxygen saturation 100% on room air. On physical examination, he was in no acute distress but appeared lethargic. The cardiopulmonary examination was inconclusive for abnormalities. The abdomen was soft and non-tender without organomegaly.\nHe underwent extensive diagnostic workup. The details of his laboratory studies are provided in Table .\nChest radiograph showed left-sided thoracotomy with chronically elevated left hemidiaphragm but no airspace opacity, effusion, or pneumothorax. He was started on intravenous proton-pump inhibitor therapy for upper gastrointestinal bleeding. Subsequently, EGD showed nodular, edematous and erythematous mucosa with petechial hemorrhages in the gastric fundus and body, with questionable prominence of underlying vasculature (Figure ).\nThe endoscopy was inconclusive for an active bleeding focus; duodenum appeared normal. He also received one unit of packed red blood cells. During the course of hospitalization, he continued to experience black-colored stools. His hemoglobin demonstrated a gradual downward trend, prompting the need for a second endoscopic evaluation. On day 7 of admission, repeat EGD revealed frank fresh blood along with blood clots in the proximal body of the stomach. The clots were irrigated, suctioned, and removed with Roth net. A pinpoint area under one of the removed clots was actively oozing, which mimicked a Dieulafoy’s lesion; primary hemostasis was achieved with a combination therapy using epinephrine injection, cautery, and hemoclip application (Figure ).\nOn day 10 of admission, laboratory studies showed an acute elevation of liver enzymes (alanine transaminase 1096 IU/L; aspartate aminotransferase 123 IU/L; alkaline phosphatase 47 IU/L; and total bilirubin 1.3 mg/dL). Drug-induced liver injury and obstructing lesion were considered plausible. Computed tomography (CT) with pancreatic imaging protocol revealed a large 4.2 x 2.9-cm pseudoaneurysm, likely arising from the gastroduodenal artery, located in the head of the pancreas, with evidence of moderate intrahepatic ductal dilatation and portal vein obstruction. Given the large size with compressive features of the surrounding structures, embolization of the pseudoaneurysm utilizing 11 coils with thrombin/Gelfoam injection was performed (Figure ).\nA two-day post-procedure abdominal ultrasound showed an increase in the size of the pseudoaneurysm, measuring 5.6 x 5.8 cm. Interventional radiology then repeated the embolotherapy with thrombin injection. In the next few days, he continued to report both melena and bright red blood per rectum, but his hemoglobin remained stable. On day 19 of admission, third EGD was performed, which was unremarkable for an active bleeding spot. His hemoglobin started to drop but another endoscopic evaluation was not recommended as last EGD was unremarkable. Therein, a bleeding scan showed an equivocal left-flank bleeding focus, not suggestive of a lower gastrointestinal collection, but possibly a small bowel focus with low-grade extravasation. Subsequently, his hemoglobin dropped to 6.3 g/dL, with no signs of overt gastrointestinal hemorrhage. On day 27 of admission, abdominal paracentesis ruled out hemoperitoneum and CTA abdomen showed possible hemorrhage in the left flank outside the gastrointestinal tract, possibly due to an infarcted spleen.\nAfter a discussion with surgery and gastroenterology teams, a repeat EGD with a side-viewing duodenoscope was planned. It initially demonstrated an extremely small blood-oozing spot from the ampulla of Vater. The blood extravasation increased shortly after first pinpointing the source. Over the next few seconds, the blood started to ooze at a rapid rate. In the next one minute, frank intermittent bleeding through the ampulla of Vater into the duodenum was identified (Figure ).\nThese findings were consistent with hemosuccus pancreaticus, likely due to the bleeding from the pseudoaneurysm of the gastroduodenal artery. After the precise etiology establishment, surgical intervention was considered due to prior failed attempts of embolization. However, there was a high risk of perioperative mortality given the patient’s comorbid conditions, poor clinical and performance status and complexity of the anatomical location of pseudoaneurysm. Therefore, a conservative approach was preferred by the patient and his family. On the other hand, he continued to experience intermittent hemorrhage requiring blood transfusions with episodes of hemodynamic instability. An urgent embolization of the pseudoaneurysm was planned. However, the patient and his family refused to undergo therapeutic procedures. The patient continued to worsen clinically over the next few days but he wished not to be resuscitated. He died in a couple of days following hemodynamic instability.
A 43-year-old female patient (para 9 with her last delivery two months prior) known hypertensive for 10 years presented to our department with gastrointestinal bleeding in the form of hematemesis, multiple episodes of melena, and hematochezia for one week. She also complained of weight loss and non-radiating and self-relieving epigastric pain not associated with positional changes. The patient was then assessed for causes of pseudoaneurysm formation, which primarily includes pancreatitis and cholecystitis. However, no significant abdominal tenderness, palpable abdominal mass, jaundice, flank tenderness, and increase in serum lipase and amylase were observed. The only significant findings included laboratory studies showing mild anemia with a hemoglobin of 9.6 g/dL, hematocrit of 29.5%, mean corpuscular hemoglobin (MCH) of 26.7, and red blood cells of 3.6 × 10^12/L, for which she was transfused two units of blood and started on injectable Vitamin K (10 mg, once daily), injectable tranexamic acid (500 mg, TDS), and omeprazole infusion (40 mg, once daily). After two days, her hemoglobin levels of 12.4 g/d, hematocrit of 37.5%, MCH of 26.7, and red blood cells 4.64 × 10^12/L. Meanwhile, mesenteric CT angiography also showed multiple splanchnic pseudoaneurysms involving the celiac axis trifurcation, gastroduodenal artery, superior/inferior pancreaticoduodenal artery, and jejunoileal branch of the superior mesenteric artery, and a large partially thrombosed pseudoaneurysm arising from superior pancreaticoduodenal branch causing a significant mass effect on the second part of duodenum as seen in Figure .\nBased on such findings, coiling and embolization of the corresponding arteries were planed. Accordingly, the right common femoral artery was used as the access route with a retrograde 5-Fr catheter, which provided access to the celiac trunk and then into the gastroduodenal artery using a 4-Fr C2 and microcatheter. The large aneurysm in the gastroduodenal artery was identified and crossed. Multiple other small aneurysms with secondary aterio-venous malformations were also observed. The whole flow circuit (retrograde and anterograde) to the large aneurysm was packed with multiple coils, with the aneurysm sack also being coiled can be seen in Figure .\nThe second aneurysm in the pancreaticoduodenal artery was accessed after multiple attempts, showing multiple coils of variable sizes blocking the aneurysm sack and its retro- and anterograde flow evident from Figure .\nAs seen in Figure repeat angiography revealed good outcomes, with no retrograde or anterograde filling of aneurysm and immediate complications having been observed.\nPostoperative care included augmentin administration (1 mg, intravenous; two doses) with positional changes to prevent any hematoma formation. The patient was advised to keep her head tilted on 45-degree angle. She was observed for one more day for any hematoma formation or bleeding prior to discharge.