Presentation
Amphetamine user, referred to the hospital for hematemesis and epigastric pain. She was agitated and unable to give a precise history. WBC of 16 ×109/L and HB 3.5 g/dL were remarkable lab data.
Patient Data
Multiple foci of portal venous gas are seen, a worrisome finding for gut ischemia. No abnormal bowel loop is detected, and major splanchnic vessels are patent. Gas bubbles are seen in the non-dependent gastric wall in favor of gastric emphysema. A cavity with air-fluid level is seen above the gastric pre-pyloric region, posteromedial to the duodenal bulb, connecting to it via a small defect the pancreas body forms the posteromedial boundary of the cavity and shows minimal heterogeneity and prominent lobulations mimics pancreatic trauma.
The red arrows point to hepatoportal venous gas and the blue to gastric emphysema. The yellow arrow shows the mentioned cavity, and the green depicts the gastric pre-pyloric region.
Case Discussion
The patient underwent endoscopy, and a large ulcer in the duodenal bulb was found, she received conservative medical treatment in ICU, several days after the CT scan patient emergently went to the operating room because of massive upper GI bleeding. A large defect of the duodenal bulb found on surgery, connected with the mentioned cavity. The cavity was confined to the pancreas posteromedially and contains fresh blood. Active bleeding from the gastroduodenal artery found on exploration. A perforated peptic ulcer confined by the pancreas or other organs is a penetrated ulcer.
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