Pancreatic Cancer Presenting With Hematemesis and Hemorrhagic Shock Following Anticoagulation With Unfractionated Heparin for Cancer-Related Venous Thromboembolism

Figure 1. Contrast-enhanced CT of the abdomen Contrast-enhanced computed tomography (CT) of the abdomen revealing pancreatic cancer from the descending duodenal leg to the pancreatic head (A) and duodenal invasion (B). Exposure of the pancreaticoduodenal arcade into the duodenum can be suspected (yellow arrowheads).

Figure 2. Contrast-enhanced CT of the chest Contrast-enhanced CT of the chest showing thrombi (yellow arrow) in the lower lobe branch of the left pulmonary artery (A) and in the lower lobe branch of the right pulmonary artery (B).

Figure 3. Contrast-enhanced CT and three-dimensional CT angiography immediately after hematemesis The slightly high-density area when compared to the other areas in the gastrointestinal tract on contrast-enhanced computed tomography (CT), immediately after hematemesis, is considered as gastrointestinal hemorrhage or blood clots. The parenchymal border between the duodenum and pancreatic head is indistinct, and intraluminal air is observed within this region (cyan arrows). These findings are suggestive of either duodenal or pancreatic head wall disruption, with possible exposure of the tumor surface into the duodenal lumen. Contrast-enhanced blood vessels can be identified in proximity to the tumor (magenta arrow). No obvious contrast leakage can be observed in the gastrointestinal tract or other areas (A). Three-dimensional CT angiography reveals signs of vasospasm in the pancreatoduodenal arcade, including irregular vessel calibers and filling defects, consistent with post-hemorrhagic vasoconstriction (magenta arrowheads) (B).

Figure 4. Angiography for pancreaticoduodenal arcade No contrast leakage are noted on pancreaticoduodenal arcade angiography. Pancreaticoduodenal arcade angiography shows arterial spasm (magenta arrowheads) (A). Angiography after transcatheter arterial embolization for pancreaticoduodenal arcade is shown. The loss of blood flow (yellow arrowheads) can be confirmed (B).