Answers: 1) Triad of melena/hematemesis, abdominal pain, and | Figure 1

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Answers:

1. Triad of melena/hematemesis, abdominal pain, and pulsatile abdominal mass. Other - sepsis, general malaise, weight loss, thrombosis of prior graft.

2. Computed tomography angiography (CTA) may show ectopic gas within/adjacent to aorta, aortic wall discontinuity, bowel wall thickening, contrast in bowel lumen (rare).

3. False. Endovascular treatment is temporizing/palliative.

Part 2

34 days later, patient presented with frank hematemesis and bright red blood per rectum.

Figure 1: Readmission CTA - retroperitoneal mass consistent with leiomyosarcoma metastasis. No source of bleeding identified by EGD.

Figure 2: Innumberable feeding vessels identified. Mass deemed “un-embolizable” and cryoablated.

Part 3

20 days post-ablation the patient returned with hematemesis and melanotic stools.

Figure 3: Fistulous tract between the duodenum and the retroperitoneal mass.

Figure 4: A 23mmx12cm covered esophageal stent in place. No immediate complications.

16 days post-operative patient has had no recurrent massive gastrointestinal bleed.

Case courtesy of University of Michigan Health Systems Dept. of Interventional Radiology – Resident: Sarah Moorman, MD; Attending(s): Jeffrey Forris Beecham Chick, MD, MPH, DABR and Ravi Srinivasa, MD

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