A Rare Cause of Massive Upper Gastrointestinal Bleeding

Abstract

Question: A 58-year-old woman was admitted with multiple episodes of melena. The patient had a history of surgery for colon cancer 7 years ago and underwent radiofrequency ablation for metastatic liver cancer 4 year ago. She was treated in another hospital for massive hematemesis and a transient loss of consciousness and was relieved after blood transfusion and proton pump inhibitor administration 5 days ago. Physical examination showed an anemic appearance. Laboratory tests revealed a low level of hemoglobin (73 g/L). An emergency gastroscopy in our department revealed a bleeding gastric ulcer, blood-like fluid effusion in stomach lumen (Figure A). What is the most likely cause of upper gastrointestinal (GI) bleeding in this patient? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Abdominal enhanced computed tomography (CT) scanning revealed multiple metastatic tumors in the liver (Figure B, black arrows) and the body and tail of pancreas (Figure B, white arrow). Importantly, invasion of stomach wall by the neighboring pancreatic tumors led to the formation of a gastric fistula, through which the contrast media was leaking into stomach lumen. CT angiography and vascular reconstruction further confirmed tumor erosion of the splenic artery and the formation of splenic artery pseudoaneurysm (SAPA) as well as tumor–gastric fistula (Figure C, D). Digital subtraction angiography also demonstrated extravasation of contrast media from SAPA through the fistula (Figure E). The patient was treated by splenic artery embolization. Postoperative angiography revealed complete blockade of the SAPA (Figure F). An enhanced CT examination on the following day showed no sign of active bleeding. The patient recovered uneventfully and was discharged without any symptoms over a 6-month follow-up period. Splenic artery aneurysms are the most common visceral artery aneurysms and are broadly classified as true aneurysms and pseudoaneurysms.1Illuminati G. LaMuraglia G. Nigri G. Surgical repair of an aberrant splenic artery aneurysm: report of a case.Ann Vasc Surg. 2007; 21: 216-218Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Causes of SAPA include pancreatitis (52%), abdominal trauma (29%), iatrogenic and postoperative causes (3%), and peptic ulcer (2%).2Wang J. Wang B. Chen D.F. An unusual cause of recurrent massive upper gastrointestinal bleeding.Gastroenterology. 2012; 143: 542Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Metastatic pancreatic tumor is rare, accounting for only 2% of all pancreatic tumors.3Lee C.W. Wu R.C. Hsu J.T. et al.Isolated pancreatic metastasis from rectal cancer: a case report and review of literature.World J Surg Oncol. 2010; 8: 26Crossref Scopus (15) Google Scholar To the best of our knowledge, SAPA caused by metastatic pancreatic tumor has not yet been reported. In the present case, the complicated patient history and endoscopic findings make the diagnosis difficult. In this scenario, enhanced CT examination and vascular reconstruction are beneficial for the diagnosis of SAPA. Superselective splenic artery embolization represents an effective approach to treat these patients with high surgical risk.