Refractory duodenal hemorrhage in the setting of aberrant SMA anatomy and celiac stenosis: a surgical rescue case report

Introduction: Upper gastrointestinal bleeding (UGIB) remains a critical clinical challenge, with peptic ulcer disease accounting for up to two-thirds of cases. While most bleeding duodenal ulcers respond to endoscopic therapy, refractory hemorrhage, particularly in the presence of arterial involvement or vascular anomalies, may necessitate escalation to interventional radiology (IR) or surgery. Case presentation: We present the case of a 64-year-old woman with a bleeding duodenal ulcer arising from an aberrant branch of the superior mesenteric artery in the setting of severe celiac artery stenosis. Despite multiple endoscopic interventions and an attempted transcatheter arterial embolization, hemorrhage persisted due to challenging vascular anatomy and tortuous arterial supply. Ultimately, emergent laparotomy with oversewing of the bleeding vessel and duodenal repair achieved definitive hemostasis. The patient experienced a prolonged but successful recovery and was discharged to rehabilitation in stable condition. Discussion: This case highlights the importance of early recognition of vascular variants and altered mesenteric flow in patients with UGIB. It also reinforces the role of surgery as a critical salvage therapy when less invasive measures fail. Conclusion: This case demonstrates the need for early multidisciplinary coordination and timely escalation to IR or surgical management in high-risk duodenal ulcer bleeding, particularly when aberrant mesenteric anatomy complicates standard approaches.