A 78-year-old Caucasian man with a history of mucosa-associated lymphoid tissue (MALT) lymphoma and chronic pancreatitis presented with epigastric pain, rectal bleeding, and melena. Both 2 months and 2 weeks before he had also been admitted with rectal bleeding and need for transfusion. His vital signs showed tachycardia of 115 beats/minute with normal blood pressure. A physical examination was unremarkable with no abdominal tenderness. Laboratory studies showed severe anemia with a hemoglobin of 4.0 g/dL. An urgent esophagogastroduodenoscopy was performed but did not reveal the source of the bleeding. CT angiography showed a (pseudo-)aneurysm of the gastroduodenal artery of 24 mm with bleeding in the small intestine (Fig. ). Digital angiography was performed and showed a high-grade ostial stenosis of the coeliac trunk with a rather broad superior mesenteric artery. Dissection of the gastroduodenal artery with a pseudoaneurysm at this level is seen after selective catheterization with a 2.7 Progreat® microcatheter (Terumo Medical Corp). This pseudoaneurysm was crossed and distally (to “close the back door”) a plurality of microcoils was placed. Then, the tip was placed just proximal to the neck of the pseudoaneurysm, and multiple coils were placed here (4 mm wide and 3 mm long). This “sandwich” technique prevents both downstream and upstream filling. Post-procedure angiography from the proper hepatic artery showed a good closure of the pseudoaneurysm (Fig. ).\nOur patient had no further gastrointestinal hemorrhage. He had an uneventful postoperative course and was discharged on the tenth postoperative day. Control CT angiography after 6 months showed complete thrombosis and resorption of the pseudoaneurysm.
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.