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Special Feature
Dec 2012

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Surgery, Tokyo Metropolitan Tama Medical Center, Fuchu (Dr Adachi), and Department of Surgery, Tokyo Metropolitan Hiroo General Hospital, Shibuya (Dr Minami), Tokyo, Japan. Dr Minami is now with the Department of Surgery, Tokyo Metropolitan Tama Medical Center.

Arch Surg. 2012;147(12):1147. doi:10.1001/archsurg.2011.2032a

A 54-year-old man with a history of chronic alcoholic pancreatitis and hepatitis presented with epigastric pain and melena, with a loss of 6 kg of body weight during the last month. He appeared anemic rather than icteric. Physical examination on admission revealed mild hepatomegaly and upper abdominal tenderness, without splenomegaly or ascites. Laboratory workup disclosed severe anemia (hemoglobin, 7.6 g/dL [to convert to grams per liter, multiply by 10.0]) and mild liver dysfunction (aspartate aminotransferase, 130 U/L; alanine aminotransferase, 96 U/L [to convert both to microkatals per liter, multiply by 0.0167]). Emergent esophagogastroduodenoscopy revealed active bleeding from the papilla of Vater (Figure 1A). Abdominal ultrasonography showed that the gallbladder was filled with debris, which color Doppler flow studies indicated was consistent with a blood clot. Enhanced abdominal computed tomographic (CT) scans are shown in Figure 1B and C.

Image not available

Figure 1. Endoscopic and computed tomographic images. A, Emergent upper gastroduodenal endoscopy demonstrated hemobilia emerging from the papilla of Vater. B, Abdominal computed tomography with intravenous contrast demonstrated massive clots in the gall bladder and duodenum. C, Another caudal slice of the computed tomographic scan.

What Is the Diagnosis?

A.  Tumor of the gall bladder

B.  Hemosuccus pancreaticus

C.  Pseudoaneurysm

D.  Carcinoma of the papilla of Vater (nonexposed type)