1060 A Rare Case of Upper Gastrointestinal Bleeding - Case Report

Abstract The most common causes of upper gastrointestinal bleeds (UGIB) are peptic and posterior duodenal ulcers, usually resulting from a gastroduodenal artery (GDA) bleed. We present a case of a patient who suffered from an UGIB after the commencement of Apixiban to treat newly diagnosed Atrial Fibrillation. Despite endoscopic intervention, clear computed tomography angiography (CTA) and GDA embolisation, bleeding persisted leading to a hypovolemic shock. (Interventional Radiology images) This is a rare occurrence which led the team to request a second CTA, revealing extravasation of contrast in the duodenum. This indicated persistence of bleeding which consequently led to an emergent surgery. The patient underwent an exploratory laparotomy and an ulcer was discovered during intraoperative endoscopy. Because of the position of the ulcer in the posterior-lateral duodenal wall, and its persistence in bleeding despite GDA embolisation it is suspected that the bleeder was most likely to be the inferior pancreaticoduodenal artery (IPDA) or an aberrant blood vessel. Our teaching points focus on the importance of considering the pancreaticoduodenal anastomosis and other anatomical variants as sources of bleeding when managing an UGIB.