64-year-old male with a past medical history of alcoholism, | Figure 1

SIRRFS

64-year-old male with a past medical history of alcoholism, chronic pancreatitis, Stage 1 squamous cell laryngeal CA treated with radiation 1 year ago, Barrett's esophagus. Recent EGD demonstrated no varices, however, an esophageal ulcer was identified which was not actively bleeding. Admitted 7 days ago with sepsis (likely C-Diff colitis) improving with oral Vancomycin. Sudden onset large volume hematemesis. Two episodes of vomiting in short sequence with an estimated 400 ml of bright red blood with clots, ICU transfer, intubation, vasopressors, massive transfusion protocol. Images following acute episode shown below (Figure 1 & Figure 2). Endoscopy performed and demonstrated fresh blood and clots in esophagus and stomach. Exploratory laparotomy revealed a 12 cm acute tear along the lesser curvature, an extremely friable 3x3 cm mass in the posterior fundus area, and 6.5 liters of blood and clot were drained from the abdomen. Incomplete hemostasis despite use of Argon beam, figure-of-eight suture, fibrin sheets and focal pressure.

Question:

  1. What would be next step in management of bleeding? a. Conservative management
    b. Endoscopy
    c. Splenic artery ligation
    d. Splenic artery coil embolization

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  1. What is the most common pathologic condition associated with GDA pseudoaneurysm?
  2. What is the appropriate management of visceral pseudoaneurysms that fail endovascular management?

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  1. What is the most common contributing branch to an arterial bleed from a breast biopsy?
  2. What is your next step in management?

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What are the risk factors for splenic artery aneurysms? What is the best management of these splenic aneurysms?

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A 33-year-old male police officer presents to the ED with severe abdominal and back pain, raising initial concern for aortic dissection. Of note, the patient reports a physical altercation with a suspect three weeks prior to presentation. Blood pressure 117/101 mmHg and hemoglobin 13.6 g/dL initially.

  1. Which of the following is not present on this patient’s CT (Figures 1&2)?
    A) Vascular aneurysm
    B) Hemoperitoneum
    C) Vascular dissection
    D) Peritoneal hematoma
  2. Celiac artery and selective splenic artery angiograms are shown above (Figure 3). Which of the following is the best next intra-procedural step?
    A) Repeat splenic angiogram with 2 second delay
    B) Repeat splenic angiogram with 20 second delay
    C) Perform visceral venogram via transjugular portal venous access
    D) Perform visceral venogram via transplenic approach

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He had a history of hypertension, long-term smoking, and a sedentary lifestyle.
On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

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