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Gastrointestinal bleeding: don’t overlook the role of the pancreas
  1. Robin Spiller, editor,
  2. G W Moran,
  3. M S H Smith,
  4. J R Butterworth
  1. Department of Gastroenterology, Royal Shrewsbury and Telford Hospital NHS Trust, Telford, UK
  1. Correspondence to:
    Dr G W Moran
    Department of Gastroenterology, Royal Shrewsbury and Telford Hospital NHS Trust, Apley Castle, Telford TF1 3QD, UK; gwmoran{at}hotmail.com

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Clinical presentation

A 59 year old man was admitted with a three day history of haematemesis and malaena. He was known to suffer from hyperlipidaemia and type II diabetes. He had a history of acute gall stone pancreatitis complicated by pseudocyst formation and treated with an open cystgastrostomy in 1996. He drank less than 20 units of alcohol/week and was a non-smoker. His medication included aspirin, metformin, and simvastatin. On admission he was hypotensive (90/70 mm Hg) and tachycardic. There were no clinical signs of stigmata of chronic liver disease. Abdominal examination was unremarkable. On admission, haemoglobin was 4.4 g/dl, international normalised ratio 1.4, urea 21.2 mmol/l, and glucose 30.4 mmol/l. The patient was resuscitated with blood and intravenous crystalloid and underwent an urgent upper gastrointestinal endoscopy followed by an abdominal computed tomography (CT) scan.

Question

What does the duodenal endoscopic image (fig 1) demonstrate? What is shown on the abdominal CT scans (figs 2, 3)?

Figure 1

 Endoscopy of the proximal duodenum.

Figure 2

 Computed tomography scan of the abdomen.

Figure 3

 Computed tomography scan of the abdomen (portal venous phase).

See page 113 for answer

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