Rare, Life-Threatening Duodenal Bleeding

Abstract

Question: A 61-year-old male born in Ethiopia with a past medical history of hepatitis B carrier, tuberculosis, arterial hypertension, and aortic valve replacement (on coumadin treatment since 2009), presented with epigastric pain radiating to the right upper quadrant. The pain worsened after meals and was accompanied with a weight loss of 5 kg in the last month. He had recently discharged from the Neurosurgery Department with dexamethasone treatment for subdural hygroma. On physical examination, the patient was afebrile with normal blood pressure and soft abdomen with diffuse mild tenderness. Initially, laboratory examination was remarkable for mild normocytic normochromic anemia 11.6 g/dL, mean corpuscular volume of 84.4, normal white cell count of 7800/mm 3 (normal range, 4500-11,000/mm 3) with absolute eosinophil count of 300/mm 3 (normal range, 0-700/mm 3), international normalized ratio of 10.8, albumin 18 g/L, C-reactive protein 111 mg/L (normal, <5), sodium 127 mmol/L, and potassium 3.5 mmol/L. All other biochemical tests, creatinine, liver enzymes, pancreatic enzymes, and HIV screening revealed normal findings. Twenty-four hours after his admission, the patient developed massive hematemesis. An urgent upper gastrointestinal (GI) endoscopy showed severe duodenitis in the bulbus continuing down to the second part of the duodenum accompanied by multiple ulcers covered with exudate (Figure A, B). The mucosa was bleeding to touch and no definite bleeding vessel was identified. Biopsies were taken from the lesions and he began proton pump inhibitor drip. Over the following 8 hours, he developed recurrent hematemesis and hypotension and computed tomography angiography revealed extensive damage to the proximal small bowel (Figure C, D). Because of the high surgical risk, a selective embolization of the gastroduodenal artery was performed (Figure E, F). Despite this approach the patient continued to bleed and required blood transfusions. Correlating these clinical and endoscopic findings with the patient's history and background.