Splenic artery aneurysm bleeding via the ampulla of Vater.

Finding the cause of obscure-overt gastrointestinal (GI) bleeding is often a difficult and time-consuming process. Despite extensive research, up to 20% of patients remain undiagnosed [1,2]. We present the case of a 74-year-old man with a history of acute pancreatitis, who was hospitalized several times in district hospitals for hemodynamically significant, recurrent, GI bleeding. The patient required transfusion of 46 units of packed-red blood cells and 16 units of fresh frozen plasma in total (the lowest hemoglobin level was 5.4g/dL) over a period of 5 months. Multiple endoscopic examinations revealed the presence of hematin and frank blood and/or clots in the upper and lower GI tracts, but the exact bleeding source remained unknown. Computed tomography showed a pancreatic tail pseudocyst and a splenic artery aneurysm (●" Fig.1). Technetium-labeled red blood cell scintigraphy confirmed a focus of increased radiotracer activity in the left upper GI quadrant (●" Fig.2). Duodenoscopy was performed, during which a blood clot and fresh blood could be seen flowing from the ampulla of Vater (●" Fig.3, ●" Video 1). The patient was diagnosed with an aneurysm that was bleeding into the pancreatic cyst, with periodic evacuation of blood via the pancreatic duct into the lumen of the GI tract. Emergency selective celiacography was unsuccessful due to the sharp angulation of the splenic artery (●" Fig.4); thus, a surgical splenopancreatectomy