ELECTRONIC IMAGE OF THE MONTH A Rare Cause of Life-Threatening Upper Gastrointestinal Bleeding Crinò Stefano Francesco, Armellini Elia, and Occhipinti Pietro Gastroenterology Division, Azienda Ospedaliero Universitaria “Maggiore della Carità”, Novara, Italy

64-year-old patient was referred to the Emergency Department for hematemesis and melena with hemorrhagic shock. The medical history showed a standard pylorus-preserving Traverso–Longmire pancreaticoduodenectomy 6 weeks earlier for adenocarcinoma, complicated by a grade A pancreatic fistula. No blood was visible in the abdominal drainage. Laboratory investigations indicated severe anemia (hemoglobin level, 6.5 g/dL). After volume resuscitation, an esophagogastroduodenoscopy was performed, which showed digested blood in the stomach without an active source of bleeding. Remarkably the duodenojejunal anastomosis was regular except for a small mucosal erosion at the perianastomotic site (Figure A).


An abdominal computed tomographic angiography showed a small gastroduodenal artery stump pseudoaneurysm (Figure B, black arrow) as a potential source. Angiography confirmed the diagnosis (Figure C) and an immediate embolization by 3 coils was performed with complete exclusion of the pseudoaneurysm (Figure D) and stable control of the bleeding. Common complications of a pancreaticoduodenectomy include delayed gastric emptying, anastomotic leakage, pancreatic fistula, intra-abdominal abscess, and gastrointestinal or intra-abdominal hemorrhage. Hemorrhage involves 2% to 8% of patients and, although uncommon, is a life-threatening event, with a reported mortality rate of 18% to 47%.

Clinical Gastroenterology and Hepatology 2015;-:-–-

ELECTRONIC IMAGE OF THE MONTH, continued Hemorrhage is defined by 3 parameters: onset, location, and severity. The onset is either early (24 hours after the end of the index surgery) or late (>24 h after the end of the index surgery). The location is either intraluminal or extraluminal. The severity of bleeding may be either mild or severe. Early bleeding (

A Rare Cause of Life-Threatening Upper Gastrointestinal Bleeding.

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