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An unusual cause of hemobilia diagnosed on EUS

Open AccessPublished:March 31, 2017DOI:https://doi.org/10.1016/j.vgie.2017.02.006
      A 33-year-old man presented with massive hematemesis associated with melena. His hemoglobin was 6 gm/dL, and he was hemodynamically unstable. He had experienced an episode of idiopathic acute pancreatitis 3 weeks earlier. After hemodynamic stabilization, upper GI endoscopy revealed a blood clot in the duodenum but no source of bleeding. Side-viewing endoscopy showed normal results. Contrast-enhanced CT of the abdomen with angiography revealed a peripancreatic fluid collection and no source of upper GI bleeding. Linear/radial EUS was performed in an attempt to discover the cause of the overt obscure GI bleeding and to evaluate the idiopathic acute pancreatitis. Linear EUS from the duodenal bulb revealed an 8-mm × 7-mm anechoic cystic-appearing lesion in the head and neck region of the pancreas adjacent to the common bile duct (CBD) (Fig. 1A). On color flow and Doppler imaging, vascular flow was seen in the anechoic area (Fig. 1B; Video 1, available online at www.VideoGIE.org), which confirmed the vascular nature of lesion. On pulse Doppler imaging, an arterial wave pattern was seen (Fig. 1C) in the vascular lesion, whose origin appeared to be the gastroduodenal artery (GDA) (Figs. 1B and C; Video 1). Radial EUS from the duodenal bulb confirmed the vascular lesion to originate from the GDA (Fig. 1D). EUS showed a characteristic “yin-yang” flow with a bidirectional waveform pattern on color Doppler US (Fig. 1E). The patient underwent mesenteric angiography, which confirmed the diagnosis of GDA pseudoaneurysm, and contrast medium in the bile duct confirmed hemobilia as the cause of the overt GI bleeding. The pseudoaneurysm was successfully embolized with coils, and at a 3-year follow-up visit, the patient remained asymptomatic.
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      Figure 1A, Linear EUS from the duodenal bulb showing an 8-mm × 7-mm cystic-appearing lesion in the head/neck region of the pancreas. B, Color-flow and Doppler image showing vascular flow in the anechoic area. C, Pulse Doppler image showing arterial wave pattern in the vascular lesion whose origin appears to be the gastroduodenal artery. D, Radial EUS view from the duodenal bulb showing the vascular lesion to be originating from the gastroduodenal artery. E, Radial EUS view revealing characteristic “yin-yang” flow with bidirectional waveform pattern on color Doppler US. CBD, common bile duct; PD, pancreatic duct.
      Pseudoaneurysms can occur in both acute and chronic pancreatitis; however, they are more common in chronic pancreatitis and are often associated with pseudocysts. Pancreatic pseudoaneurysms are relatively rare. GI bleeding is the most common clinical presentation. Pseudoaneurysms can rupture into the GI tract directly or indirectly. The latter is often due to hemosuccus pancreaticus or hemobilia. The most common artery involved is the splenic artery, followed by the gastroduodenal/pancreaticoduodenal and hepatic arteries. GDA aneurysms are rare but are potentially fatal if rupture occurs. Only a few case reports have shown the diagnostic utility of EUS in obscure GI bleeding in acute pancreatitis. The present case highlights the possible role of EUS in the diagnosis of obscure upper GI bleeding in pancreatitis.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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