Case presentation
A 45-year- old man with a 20 year old history of duodenal ulcer presented to our hospital with vomiting and tarry stool. There was no abnormality with the physical examination, and laboratory data did not show anemia on admission, but few hours after he suddenly presented a hemorrhagic shock. The emergency endoscopy performed did not find upper gastrointestinal bleeding. Computed tomography (CT) revealed dilated blood vessels in the lower part of the descending duodenum, and spotty staining of the pancreatic uncinate process at the early phase (Fig.1) and the next day multifocal bleeding from the edematous duodenal mucosa near the papilla of Vater (Fig.2) were observed with endoscopy.
Considering the possibility of bleeding due to vascular lesions such as Ph-AVM based on CT findings, interventional radiology was performed for further diagnosis and treatment. Angiography revealed the definitive diagnosis of Ph-AVM with abnormal reticular blood vessels in the descending limb of the duodenum (Fig.3). Coil embolization failed in complete hemostasis, thus we decided to perform emergency surgery. A typical pancreatoduodenectomy was performed. Surgical findings showed the proliferation of abnormally dilated blood vessels at the pancreatic head. The operation time lasted for 5 hours, and the amount of bleeding was 500g.
Histopathological findings showed collections of irregularly tortuous blood vessels within the thick wall of the duodenal proper muscle layer adjacent to the pancreatic parenchyma near the major duodenal papilla. Fibrin thrombi were occasionally seen in the pancreatic parenchyma and submucosa of the duodenum (Fig.4).
The postoperative course was uneventful, and the patient was discharged 32 days after surgery, and he has remained in excellent health so far for 4 years and 9 months.