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Rajaraman Durai , Daniel Thomas, Ahmad El Gaddal, Midhat Siddiqui
British Journal of Hospital Medicine, Vol. 72, Iss. 5, 10 May 2011, pp 293

A 46-year-old man presented with left upper quadrant pain. Previously he had suffered two massive episodes of upper gastrointestinal bleeding and had undergone a gastroscopy, colonoscopy and ultrasonography. Apart from some nodular gastritis his endoscopies were essentially normal. Ultrasonography demonstrated a 15cm splenomegaly.
During this admission, computed tomography demonstrated a 16mm splenic artery pseudo-aneurysm, splenic infarcts and surrounding haematomas (Figures 1 and 2). His pseudo-aneurysm may have eroded and bled into the pancreatic duct in the past (haemosuccus pancreaticus), which could explain his gastrointestinal bleeding with normal endoscopies. The cause of splenic infarct is thromboembolism secondary to the pseudo-aneurysm. The patient was referred to the regional vascular unit for possible angioembolization.
In cases of upper gastrointestinal bleeding with normal endoscopies, a computed tomography scan should be considered if appropriate. In the investigation of gastrointestinal haemorrhage a precontrast computed tomography should be performed to look for hyperdense blood in the bowel (indicating a recent bleed) and an arterial phase computed tomography to look for active bleeding at the time of the scan.

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