S3451 Massive Gastrointestinal Hemorrhage as an Initial Presentation of Invasive Pancreatic Cancer

Introduction: Pancreatic cancer is an uncommon cause of gastrointestinal hemorrhage. Pancreatic carcinoma can directly invade the stomach and lead to acute gastrointestinal bleeding. However, the reported incidence remains very low. We present a rare case in which a patient’s initial symptoms of invasive pancreatic cancer were hematemesis and hematochezia. Case Description/Methods: A 54-year-old woman with a past medical history of hypertension presented to the emergency department with 2 episodes of vomiting bright red blood and 2 bloody bowel movements. The patient reported using ibuprofen over the past 2 weeks during a viral illness. She was hypotensive and tachycardic. Laboratory results showed a hemoglobin of 9.9 g/dL, a significant drop from her baseline. The patient was started on a proton pump inhibitor drip and underwent an urgent esophagogastroduodenoscopy (EGD). It showed massive gastrointestinal bleeding with fresh blood and clots in the esophagus, stomach, and duodenum. She received blood transfusions and vasopressor support. Computed tomography angiography revealed active extravasation of contrast from the distal splenic artery into a pancreatic tail mass lesion, eroding into the posterior wall of the stomach and resulting in a large intragastric hematoma. The patient underwent splenic pseudoaneurysm embolization and was further stabilized with 4 units of packed red blood cells and 1 unit of cryoprecipitate. A repeat esophagogastroduodenoscopy revealed a perforation and necrotic area at the gastric cardia where a pancreatic mass had eroded into the stomach wall. Immunohistochemical analysis of biopsy samples was consistent with primary pancreatic adenocarcinoma. Discussion: Pancreatic tumors typically present with nonspecific symptoms such as weight loss, jaundice, or abdominal pain. However, our patient’s initial presentation involved massive gastrointestinal bleeding from a pancreatic tail mass eroding into the gastric cardia which is not a common site of involvement. A splenic artery pseudoaneurysm can rarely rupture as a complication of pancreatic tail tumors, given their proximity to the splenic vessels. While the patient’s nonsteroidal anti-inflammatory drug use may have contributed to mucosal injury, the extent of bleeding was severe enough to consider a broader differential diagnosis including structural causes. This case also highlights the aggressive nature of pancreatic cancer and the life-threatening vascular complications that can result from its direct invasion.