A 47-year-old male, nonsmoker with no significant medical history initially presented with sudden onset right-sided chest pain, fever, and shortness of breath. After a hemorrhagic pleural tap and chest x-ray demonstrating large retro cardiac soft tissue density, gross right pleural effusion, and right lower lobe lung collapse the patient was referred to our center with a working diagnosis of thoracic malignancy and large lung carcinoma with hemorrhagic pleural effusion.\nThe patient was admitted to our center for further workup. Immediately after, the patient experienced severe respiratory distress; oxygen saturation (SpO2) was 74% on two liters of oxygen. The patient was transferred to the intensive care unit (ICU) with pulse: 102 beats per minute and regular, blood pressure: 95/79 mm Hg, respiratory rate: 22/minute, temperature: 97°F, and SpO2: 100% on high-flow oxygen. Glasgow Coma Scale (GCS) was 15/15, and on examination of the chest, there was decreased air entry on the right side. A right-sided chest drain was placed; 1300 ml of hemorrhagic fluid was drained by the end of the day. Total leukocyte count (TLC) then was 21710/mm^3. A blood and sputum culture was obtained. The sputum sample demonstrated Klebsiella pneumonia, which was managed accordingly, normalizing the counts on the days to come. Whole blood was transfused during the ICU stay as required. After three days the patient was shifted to the general ward with the drain holding 50 ml of blood and stable vital signs.\nCECT chest performed on the fifth day of admission demonstrated a large lesion involving the subcarinal region with intensely enhancing focus adjacent to right bronchus intermedius likely pseudoaneurysm with associated hematoma, collapse of basal right-lower lobe, and collection in the right pleural space (Figure ). The plan for the trucut biopsy of the lung was deferred, and a bronchial angiogram with embolization for bronchial artery pseudoaneurysm was planned. The right common femoral artery was accessed with a 5 French gauge (Fr) vascular sheath, a diagnostic angiographic catheter (Shepherd catheter 5 Fr, Cook Medical, USA) aided in cannulating the right bronchial artery. A selective angiogram revealed a pseudoaneurysm with patent distal flow (Figure ). After the introduction of the 2.1 Fr microcatheter (Artec microcatheter, Japan) the distal normal arterial lumen was reached and coiled with a 2 mm x 2 mm pushable coil (Cook Medical, USA). Similarly, a 2 mm x 2 mm pushable coil was used to trap the front door/proximal part of the right bronchial artery. Post coil embolization, angiogram after 15 minutes showed reduced flow to the sac; however, complete thrombosis was not seen (Figure ). Another permanent embolizing agent Glue mixed with lipiodol (1:7 ratio) was used to achieve complete embolization endpoint. The final angiogram revealed complete thrombosis of the pseudoaneurysm sac and the right bronchial artery (Figure ). No immediate complications were noted. Hemostasis was achieved at the groin by manual compression. After a few days, the chest tube was removed due to a minimal drain.\nFollow-up CT angiography showed coils in the subcarinal region without obvious abnormal enhancement suggestive of adequate embolization and a slight decrease in the size of hematoma at the subcarinal region. The patient was hemodynamically stable and symptomatically better, thus was discharged after one week of hospital stay. The patient was re-evaluated after three weeks by a CECT chest, which showed a significant interval decrease in the lesion at the subcarinal region, subsegmental collapse of a basal segment of the right lower lung, and a significant decrease in the pleural collection (Figure ).
A 55-year-old male diagnosed case of ethanol-related chronic pancreatitis presented with frequent episodes of melena associated with paroxysms of abdominal pain. He was given blood transfusions elsewhere for severe anemia. As patient had persistent GI bleeding with repeated drop in hemoglobin, he was referred for further evaluation and management. On clinical examination, he had profuse sweating, hypotension, tachycardia, severe pallor and mild tenderness in the epigastrium. His laboratory investigations revealed hemoglobin of 7.1 g% and hematocrit of 22%, mild renal failure and increased serum triglycerides. Contrast-enhanced computed tomography of the abdomen showed evidence of chronic calcifying pancreatitis (). Esophagogastroduodenoscopy with a standard scope and colonoscopy were normal. Repeat esophagogastroduodenoscopy with a standard scope after an episode of melena showed active bleeding from the ampulla (). Angiographic study could not localize the site of bleeding. Endoscopic ultrasound showed chronic pancreatitis with a heterogeneous inflammatory lesion in the body of the pancreas (). As the bleeding source could not be localized and the patient had ongoing melena and drop in hemoglobin, emergency exploratory laparotomy was performed after initial hemodynamic stabilization. Pancreas was seen adherent to splenic vessels and hilum. There was evidence of splenic vein rupturing into the main pancreatic duct. Distal pancreatectomy with splenectomy was performed. The patient had an uneventful recovery postoperatively. Postoperative histology demonstrated chronic calcifying pancreatitis (), lymphnodes with reactive hyperplasia and congested spleen (). He was discharged in a hemodynamically stable condition and there was no further recurrence of GI bleeding after 6 months of follow up.