An unusual cause of recurrent massive upper gastrointestinal bleeding.

Question: A 50-yearold man presented with acute onset of massive hematemesis and a transient loss of consciousness. He denied acid reflux, or abdominal pain or distension. His past history revealed bleeding duodenal ulcer diagnosed by endoscopy 1 year ago. Although treated with esomeprazole continuously, he suffered from recurrent hematemesis 4 times during the last year. Physical examination showed unstable vital signs with hypotension (92/70 mmHg) and tachycardia (heart rate, 106 bpm). The patient was treated conservatively with fluid infusion and esomeprazole. After 2 episodes of melena, there were no signs of massive rebleeding. Gastroscopy was performed and blood-like fluid effusion in the duodenal bulb was detected (Figure A). After washing with normal saline, a deep ulcer-like lesion ith a diameter about 0.2 cm was revealed on noninflamed duodenal mucosa (Figure B). Both cross-sectional (Figure C) and coronal (Figure D) maging of contrast-enhanced computed tomography (CT) showed a large hematoma between the duodenal bulb and pancreas in the artery hase. What is the most likely cause of upper GI bleeding in this patient? Look on page 872 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.