Endoscopy-negative upper gastrointestinal bleeding in a patient with chronic pancreatitis

Dr. C. Me1 Wilcox: A 54-year-old man with a history of alcohol-induced chronic pancreatitis presented to the hospita1 with worsening abdominal pain, hematemesis, melena, and postural symptoms. He was in his usual state of health until 3 months before admission, when he underwent esophagogastroduodenoscopy for an exacerbation of chronic epigastric pain after an unsuccessful empirie trial of antiulcer therapy. Endoscopic findings included mild esophagitis and proximal gastritis. At that time, the hemoglobin was 130 g/L (13 g/dL) and the serum amylase concentration was 2.47 pkat/L (148 U/L) [upper limit of normal, 1.83 pkat/L (110 U/L)]. To further evaluate the abdominal pain, abdominal ultrasonography was performed demonstrating a sonolucent structure in the head of the pancreas measuring 5.1 X 3.8 cm, compatible with a pseudocyst. The common bile duet was noted to be 1.2 cm in diameter. Abdominal computed tomography (CT) at that time with IV contrast confirmed the presence of a pancreatic pseudocyst. In addition, abundant pancreatic calcifications were noted. He was begun on H,blocker therapy with some amelioration of pain. Six weeks before admission, a subsequent abdominal ultrasonography showed no change in the size or appearance of the pseudocyst. The pseudocyst was to be observed for another 6 weeks before deciding on therapy. Five days before admission, he noted the onset of worsening epigastric pain characterized as crampy and burning. The following day he noted the presence of black stool. Over the next 3 days, intermittent nausea and vomiting of bright red blood as wel1 as postural symptoms occurred, and he went to the hospital. In the emergency department, a nasogastric tube aspirate showed 50 mL of bright red blood and toffee-grounds material, which cleared after 500 mL of tap water lavage. He was thus admitted. His medical history was notable for alcohol-induced chronic pancreatitis and mild intermittent chronic abdominal pain of 3 years’ duration. Two years before admission, he was found to have an esophageal ulcer by esophagogastroduodenoscopy, presumed to be acid-peptic in origin by endoscopic and histopathological criteria. He underwent a laparotomy for colonic perforation after colonoscopic polypectomy 2 years previously. There was no pancreatie disease in his family history. He smoked one pack of cigarettes per day for more than 20 years. Although previously drinking six or more beers per day, he was currently consuming one to three beers per week. Admission physical examination showed a thin man in no apparent distress with blood pressure 155,/105 mmHg, pulse 104 beats/min, respirations 20 breaths/min, and temperature 37°C. With upright posture, his blood pressure decreased to 140/90 mmHg with a pulse increase to 120 heats/ min. Head and neck examination showed no abnormalities. The lungs were remarkable for an increased expiratory phase. Cardiac examination showed a tachycardia and a soft flow murmur at the base. Soft bruits were present over the femoral arteries. The abdomen was scaphoid with a well-healed midline star. Bowel sounds were present and no abdominal bruits were audible. Mild epigastric tenderness was present with palpation in the absente of any mass lesions; hepatosplenomegaly and rebound