S4769 Gastrointestinal Hemorrhage Secondary to Pancreaticoduodenal Aneurysm Into Duodenum

Introduction: Pancreaticoduodenal artery (PDA) aneurysms, a rare type of visceral artery aneurysm (VAA), infrequently cause intraluminal gastrointestinal (GI) bleeding. We discuss the case of an 85-year-old man who developed an aneurysm of the inferior pancreaticoduodenal artery with erosion into the duodenum, causing symptomatic bleeding. Case Description/Methods: An 85-year-old man with a history of coronary artery disease on baby Aspirin presented for melena, fatigue and weakness. Hemoglobin was 4.5 g/dL with baseline 2 weeks before of 11.5 and a BUN:Creatinine ratio of 45, consistent with upper GI bleed. CTA demonstrated a pulmonary embolism and he was started on heparin, intravenous pantoprazole 40 mg twice daily, and blood transfusions. Esophagogastroduodenoscopy (EGD) was performed revealing LA grade D esophagitis, but no duodenal bleeding. Ten days later, the patient had large volume melena associated with hypotension, and repeat EGD demonstrated blood clot throughout the esophagus and stomach without a source of bleeding. A repeat computed tomography showed a PDA embedded in the wall of the second portion of duodenum with active bleeding. He underwent interventional radiology angiography that redemonstrated a PDA, but failed to show active bleeding, and no intervention performed. After bleeding subsided, blood thinners were discontinued and he was discharged. Discussion: PDAs make up about 2% of all visceral artery aneurysms. Their pathophysiology can be explained by either stenosis, occlusion or compression of the celiac artery causing increased pressure and altered blood flow within the collateral pancreaticoduodenal arcades. Celiac stenosis has been observed in about 50%-80% of patients and these aneurysms are typically discovered on computed tomography imaging of the abdomen after clinical evaluation fails to produce a diagnosis. Patients can present with a variety of symptoms including nausea, vomiting, abdominal pain, fatigue, or melena. Unfortunately, in many cases VAAs are not discovered until after catastrophic bleeding in the retroperitoneal space of the abdomen has occurred with up to a 50% fatality rate. Our case is unique as he was past the mean age of 60 with a 8 × 9 mm aneurysm that became embedded in the wall of the second portion of the duodenum with a suspected slow leak. This case helps add to the literature by highlighting a rare anatomical and clinical occurrence. Gastroenterologists should be aware of PDA aneurysms when evaluating upper abdominal pain and GI bleeding as failure to do so may lead to high mortality.