Fatal acute pancreatitis following sclerosis of a bleeding duodenal ulcer complicated by an intramural duodenal hematoma

An 80-year-old male was admitted with generalized weakness, pale skin and tarry stools. He had a past medical history of atrial fibrillation on anticoagulant therapy (warfarin) and osteoarthritis requiring more than occasional non-steroidal anti-inflammatory drugs. His blood pressure was 154/65 mmHg and he had no abdominal tenderness. Significant laboratory results showed: hemoglobin 9.4 g/dl, international normalized ratio (INR) 3.84, blood urea 141 mg/dl and creatinine 1.2 mg/dl. Upper endoscopy revealed an oozing ulcer at the bulbar apex (Forrest classification IB) that was treated with epinephrine (10 ml at 1:10,000) and polidocanol (5 ml at 1%) injection (Fig. 1). Warfarin was stopped and intravenous proton pump inhibitors initiated. After 24 h, he started to complain of progressively increasing epigastric pain. A drop in hemoglobin concentration to 6 mg/dl, a prolongation of the INR to 4.05, an elevated amylase (2,491 U/L) and lipase (16,100 U/L) were noted. He was transfused with two units of packed RBC. On abdominal ultrasound (US) no particular finding as to the cause of the pancreatitis was found. However, the abdominal complaints worsened and on day 3 an abdominal CT revealed pancreatic head edema, inflammatory changes in the peripancreatic fat and a huge intramural duodenal hematoma (14 x 6 cm) that involved the second portion of the duodenum and was associated with free peritoneal fluid and air (Fig. 2). Returning from the CT scan, the patient suffered cardiac arrest and died in spite of our best efforts to resuscitate him.