Bleeding duodenal ulcer and adenomyomatosis of gallbladder

Case contributed by Yaïr Glick


Abdominal pain, constipation, single episode of vomiting.

Patient Data

Age: 55 years
Gender: Male

Hypodense process with ill-defined borders measuring approximately 3.2 x 2.2 x 2.9 cm with a density of 50±5 HU fills the pancreaticoduodenal groove. The process exerts mass effect on both the duodenum and the head of the pancreas and contains small gas bubbles. Mild fat stranding surrounding the second duodenal segment.
The pancreas itself is preserved.
Small sliding hiatal hernia.
Mild hepatic steatosis. Tiny focus of hyperenhancement in segment 2, perhaps flash filling hemangioma.
Gallbladder fundus shows thickened, enhancing wall. No gallstones detected.

Normal-appearing retrocecal appendix.

Posterior L4-L5 disc herniation, exerting pressure on the thecal sac and narrowing the left neural recess.


In summary

Ill-defined process in pancreaticoduodenal groove containing gas bubbles, with surrounding mild fat stranding. Most compatible with bleeding perforated duodenal ulcer.
Differential diagnosis includes:

  • pancreatic adenocarcinoma: mass appears to displace head of pancreas rather than occupy it, no other manifestation of pancreatic carcinoma (pancreas preserved, no dilation of bile ducts or main pancreatic duct, etc.); mass contains bubbles
  • groove pancreatitis: no history of pancreatitis; medial duodenal wall is displaced, not thickened, and CBD is not dilated

The patient underwent ultrasonographic investigation of his partly thickened gallbladder.

Partially distended gallbladder not containing gallstones. Gallbladder wall mildly thickened with numerous cholesterol crystals (comet tail sign), some with calcification (twinkle artifact).

Gastroduodenoscopy showed massive bleeding from a duodenal ulcer.
Angiography was then performed for localization and embolization of the bleeding vessel.

Right transfemoral access via 5F introducer sheath, hemostasis with Angioseal 6F.
No active bleeding detected.
Embolization of the entire length of the gastroduodenal artery done with many coils, 3 and 4 mm in diameter.
Last (proximal) coil, 4 mm, passed into a hepatic subsegmental artery. Extraction attempt with snare unsuccessful.

Case Discussion

Since the patient initially presented with vague abdominal complaints and an initial KUB (not shown) was interpreted as normal, he underwent abdominal CT scanning. The CT findings, highly suspicious for a bleeding duodenal ulcer, were validated on gastroduodenoscopy. DSA was performed where, even though there was no demonstration of active bleeding, the gastroduodenal artery (GDA) was correctly surmised to be the culprit artery since it supplies the proximal duodenum.

The gallbladder fundal wall thickening turned out to be adenomyomatosis.

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