Gastroenterology image challenge: A 75-year-old woman presented to the emergency department with two weeks of nonradiating epigastric pain and nausea. Her medical history was notable for collagenous colitis treated with budesonide, hypertension and remote cholecystectomy for cholecystitis. She reported approximately 6 oz of daily alcohol consumption with no tobacco or illicit drug use.
Her vital signs were significant for a blood pressure of 215/105 mm Hg and was otherwise within normal limits. Physical examination was remarkable for epigastric tenderness. The initial laboratory workup revealed a hemoglobin of 10.0 g/dL with unremarkable metabolic and liver chemistries. Triglyceride level was 164 mg/dL, and lipase of 101 U/L.
Computed tomography (CT) imaging revealed diffuse inflammatory changes of the pancreas with an inferior pancreaticoduodenal artery pseudoaneurysm (figure A). Minutes after finishing the CT scan, the patient became unresponsive and hypotensive. Repeat CT imaging after fluid resuscitation revealed a large amount of intraperitoneal blood (figure B). This prompted emergent interventional radiology-guided coil embolization. An angiogram during the procedure revealed segmental narrowing with areas of ectasia of the right hepatic arterial vasculature concerning for vasculitis (figure C).
After the patient was stabilized, she developed melenic stools and dysphagia with pills. Esophagogastroduodenoscopy revealed circumferential ischemic appearing esophagitis of the distal third of the esophagus as well as ischemic appearing duodenitis with ulceration consistent with recent embolization (figure D, E).
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