RT Journal
A1 Adachi K, Minami T
T1 IMage of the month—quiz case
JF Archives of Surgery
JO Archives of Surgery
YR 2012
FD December 1
VO 147
IS 12
SP 1147
OP 1147
DO 10.1001/archsurg.2011.2032a
UL http://dx.doi.org/10.1001/archsurg.2011.2032a
AB 
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.