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 39-year-old man was admitted to the hospital due to hematemesis and melena for 2 wk, with a new episode lasting 1 d.\nTwo weeks before admission, the patient had hematemesis and melena without obvious known causes. He vomited light red fluids 4-5 times/d and passed tarry stools 3-4 times/d; these events were accompanied by epigastric pain, abdominal distension, and fatigue. He had no dizziness or syncope. He was hospitalized at a local hospital where examinations showed a hemoglobin (Hb) level of 86 g/L. Esophagogastroduodenoscopy (EGD) showed fresh blood in the descending part of the duodenum but did not show a clear bleeding site. The patient was treated with blood transfusion, acid blockers, and intravenous (IV) fluid and discharged from the hospital after no recurrence of hematemesis or melena was observed.\nOne day before admission to our hospital, the patient vomited bright red blood once and was admitted to the local hospital. Bedside EGD showed no obvious bleeding in the upper gastrointestinal tract. During his hospitalization, the patient had repeated hematemesis and hematochezia 4-5 times/d accompanied by left upper abdominal pain and fatigue. His minimum Hb level was 42 g/L. After treatment with blood transfusion, IV fluid, acid blockers, and hemostasis, he was transferred to our hospital for emergency admission.\nThe patient had a history of chronic pancreatitis. He denied chronic diseases such as hypertension, coronary heart disease, and diabetes, a history of abdominal surgery and trauma, and a history of food and drug allergy.\nThe patient denied a history of smoking and drinking and any history of diseases in family members.\nOn admission, the patient had a body temperature of 37.2 °C, a pulse of 102 beats/min, a respiratory rate of 19 times/min, a blood pressure of 117/91 mmHg, and an oxygen saturation of 98%. The patient had manifestations of anemia and pale conjunctiva. His abdomen was soft with upper abdominal tenderness. No rebound tenderness was noted. No abdominal mass was palpable. No other obvious abnormality was noted.\nThe complete blood count on admission was as follows: White blood cell count, 8.00 × 109/L; red blood cell count, 2.34 × 109/L; Hb, 66 g/L; hematocrit, 0.192; platelet count, 108 × 109/L; total amylase, 198 U/L; D-dimer, 6060 µg/L; hypersensitive C-reactive protein, 40.1 mg/L; procalcitonin, 0.12 ng/mL; and serum albumin, 24 g/L (Table ). Coagulation function, alanine aminotransferase, aspartate aminotransferase, total bilirubin, alkaline phosphatase, glutamyl transpeptidase, urinalysis results, stool analysis, tumor marker expression, troponin I, and electrocardiogram results were all within normal limits.\nA noncontrast-enhanced computed tomography (CT) scan of the abdomen and pelvis showed pancreatic swelling, uneven density, vague edges, multiple spots of calcifications, and hyperintense opacities in the pancreatic head and body, indicating chronic pancreatitis and pancreatic head hemorrhage.\nSubsequent contrast-enhanced CT of the abdomen showed isointense, rounded opacities with a diameter of approximately 41 mm in the pancreatic head that were enhanced with contrast in the arterial phase and were closely related to the gastroduodenal artery, indicating pseudoaneurysm (Figure ). Furthermore, digital subtraction angiography performed via the celiac trunk showed the formation of pseudoaneurysms at the proximal gastroduodenal artery; the remaining blood vessels were unremarkable (Figure , Video 1A).