Exposé: Different Faces of a Bleeding Giant Duodenal Ulcer

Excerpt

A 78-year old woman was brought to the Emergency Department by paramedics because of hematemesis, melena, and severe hypotension. She had a background history of mild dementia, chronic alcoholism and compensated alcoholic cirrhosis, chronic iron deficiency anemia, chronic left foot neuropathic ulceration, seizure disorder, and a remote history of breast cancer, cerebrovascular accident, and fall-related pelvic fracture. There was no history of prior cigarette smoking, or peptic ulcer disease. At presentation, she was lethargic, hypotensive (BP = 84/40) and mildly tachycardic and tachypneic. Her hemoglobin was 9.8 mg/dl, but after initial fluid boluses, it dropped to 7.4 despite the transfusion of two units of blood. She reported no abdominal pain. Her heart and lung examination was normal; her abdomen was obese but soft without organomegaly. She did not have any stigmata of cirrhosis or ascites. Electrocardiogram and troponin levels suggested demand anterolateral cardiac ischemia. Therapy with intravenous octreotide and a proton pump inhibitor (PPI) were initiated. After admission to the intensive care unit, an urgent upper endoscopy revealed a normal esophagus and stomach but torrential bleeding emanating from the duodenal bulb (Fig. 1a) that could not be well visualized. Given her precarious clinical state, the endoscopy was aborted and she underwent an urgent celiac and mesenteric arteriogram that revealed contrast extravasation from the gastroduodenal artery (Fig. 2a). Selective coil embolization was successfully performed (Fig. 2b). For the next four days, she remained hemodynamically stable while receiving IV PPI and clear liquids.

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