We present the case of a 66 y o gentleman who had chronic pancreatitis and abdominal pain who underwent a pancreatic head resection and a Peustow procedure. The post-operative course was complicated by the development of an intra-abdominal hematoma. The hematoma is shown by the arrow here on the CT scan. An angiogram demonstrated an aneurysm of the pancreatico-duodenal artery which was treated with coil embolization.
He presented 4 weeks later with melena and abdominal pain. On physical exam he was tachycardic, pale, hypotensive with epigastric tenderness and a hemoglobin of 6.9. A push enteroscopy to the entero-enteral anastomosis was normal. A colonoscopy with terminal ileal intubation showed fresh blood. We decided to perform a spiral enteroscopy to evaluate the cause of the obscure overt GI bleeding. The enteroscope is seen here being advanced through the duodenum into the pancreatic parenchyma. On entering the pancreatic parenchyma, we noted evidence of fresh blood as well as old clots. The pancreatic side branches were seen as evidenced by this arrow here. Upon investigating further, we noted that the coils from the coil embolization had protruded through the pancreatic parenchyma and were causing bleeding as seen by the fresh blood and clots surrounding it.
We determined that there was nothing that we could do endoscopically to stop the bleeding and therefore the patient was referred back to interventional radiology and underwent repeat coil embolization with placement of 4 additional coils. His hemoglobin stabilized and he was discharged home. His hemoglobin remains stable at 6 months and 12 months of follow up.
This case demonstrates how spiral enteroscopy assisted pancreatoscopy helped in the diagnosis of a rare cause obscure overt gastrointestinal bleeding
Jonathan Buscaglia, MD, Stony Brook University Medical Center
Vijay Jayaraman, MD, Stony Brook University Medical Center
Mark Wilkinson, MD, Stony Brook University Medical Center