Bleeding Malignant Duodenal Ulcer in a Patient
with Celiac Axis Occlusion

Howard M. Richard, III, M.D., and
Geoffrey S. Hastings, M.D.
University of Maryland Medical Systems

Fig. 1. Lateral aortogram demonstrates celiac occlusion.

Fig. 2. Flush aortogram demonstrates extravasation into the duodenum.

Figs. 3a &3b. Early and late phase selective arteriograms demonstrate bleeding from the anterior inferior pancreaticoduodenal artery.

Fig. 3b.
Case Reference No. CC-1199-08

An 83-year-old woman presented with one day history of melena and hematemesis. She was transfused with ten units of packed RBCs and underwent emergency upper endoscopy. The duodenum was not visualized secondary to brisk hemorrhage. The endoscopist's initial impression was that she was bleeding from a duodenal ulcer or hemobilia. In support of a biliary abnormality, AST was 200 U/L, alkaline phosphatase 880 U/L, and ALT was 182 U/L; a CT later showed biliary and pancreatic duct dilatation. The patient was then referred for urgent angiography and possible embolization.

Fig. 4. Post embolization arteriogram demonstrates cessation of hemorrhage and preservation of posterior inferior pancreaticoduodenal flow to the celiac axis.
At angiography she was noted to have diffuse atherosclerotic disease and an occluded celiac axis (Fig. 1) which reconstituted via the inferior pancreacticoduodenal arteries. Brisk extravasation was noted from the anterior inferior pancreaticoduodenal artery (Fig. 2). A tracker catheter was advanced to the site of the bleeding (Fig. 3) and microcoils and a gelfoam pledget were placed into the artery. Repeat angiogram demonstrates that the bleeding has stopped (Fig. 4).

A follow-up endoscopy demonstrated a 3-cm ulcer in the duodenum, with no active hemorrhage. Endoscopic biopsy of the ulcer was positive for adenocarcinoma of the pancreas.

Questions:

1) Can hemobilia present with massive UGI hemorrhage?

2) Would you consider less selective embolization of the inferior pancreaticoduodenal artery in light of the celiac occlusion?

3) What is your embolic agent of choice in this situation?

4) What is the role for nuclear medicine studies in cases of massive UGI hemorrhage? Would you get the nuclear medicine study prior to angiography?

Related Case:

Case 0998_05 -- Pancreatic Duodenal Arcade Pseudoaneurysm and Celiac Stenosis