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Special Feature |

Image of the Month—Quiz Case FREE

Kensuke Adachi, MD, PhD; Tomohito Minami, MD, PhD
[+] Author Affiliations

Author Affiliations: Department of Surgery, Tokyo Metropolitan Tama Medical Center, Fuchu (Dr Adachi), and Department of Surgery, Tokyo Metropolitan Hiroo General Hospital, Shibuya (Dr Minami), Tokyo, Japan. Dr Minami is now with the Department of Surgery, Tokyo Metropolitan Tama Medical Center.


SECTION EDITOR: CARL E. BREDENBERG, MD


Arch Surg. 2012;147(12):1147. doi:10.1001/archsurg.2011.2032a.
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Published online

A 54-year-old man with a history of chronic alcoholic pancreatitis and hepatitis presented with epigastric pain and melena, with a loss of 6 kg of body weight during the last month. He appeared anemic rather than icteric. Physical examination on admission revealed mild hepatomegaly and upper abdominal tenderness, without splenomegaly or ascites. Laboratory workup disclosed severe anemia (hemoglobin, 7.6 g/dL [to convert to grams per liter, multiply by 10.0]) and mild liver dysfunction (aspartate aminotransferase, 130 U/L; alanine aminotransferase, 96 U/L [to convert both to microkatals per liter, multiply by 0.0167]). Emergent esophagogastroduodenoscopy revealed active bleeding from the papilla of Vater (Figure 1A). Abdominal ultrasonography showed that the gallbladder was filled with debris, which color Doppler flow studies indicated was consistent with a blood clot. Enhanced abdominal computed tomographic (CT) scans are shown in Figure 1B and C.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Endoscopic and computed tomographic images. A, Emergent upper gastroduodenal endoscopy demonstrated hemobilia emerging from the papilla of Vater. B, Abdominal computed tomography with intravenous contrast demonstrated massive clots in the gall bladder and duodenum. C, Another caudal slice of the computed tomographic scan.

WHAT IS THE DIAGNOSIS?

A.  Tumor of the gall bladder

B.  Hemosuccus pancreaticus

C.  Pseudoaneurysm

D.  Carcinoma of the papilla of Vater (nonexposed type)

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Endoscopic and computed tomographic images. A, Emergent upper gastroduodenal endoscopy demonstrated hemobilia emerging from the papilla of Vater. B, Abdominal computed tomography with intravenous contrast demonstrated massive clots in the gall bladder and duodenum. C, Another caudal slice of the computed tomographic scan.

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