1. Dilemma

2. A 53 year-old man was transferred from an outside hospital where he had been admitted 6 hours earlier because of hematemesis and melena.

3. On arrival he was alert and oriented.
Despite transfusion of 6 units of pack red blood cells, his hemoglobin had fallen to 8.8 g/dl.
On arrival he was alert and oriented.
He denied pain or other problems.

4. He had a remote history of alcohol abuse, but had stopped drinking alcoholic beverages several years ago. He was not taking medication and had not used non-steroidal anti-inflammatory drugs.

5. There were no stigmata of chronic liver disease.
The physical examination demonstrated pallor, hypotension and tachycardia.
There were no stigmata of chronic liver disease.

6. An nasogastric aspirate showed fresh blood in the stomach.
Despite repeated lavage, the aspirate did not become clear.

7. After stabilization, the patient underwent an emergency endoscopy, which only revealed two oozing Mallory Weiss tears and a large amount of blood in the stomach. There were no ulcers in stomach or duodenum.
Soon afterwards, the patient became unstable, requiring volume resuscitation, intubation and pressure support.

8. Fresh blood was aspirated from the nasogastric tube
Fresh blood was aspirated from the nasogastric tube. Despite multiple transfusions, his status did not improve.
He developed a coagulopathy with a PT of 20 s. In view of the prior endoscopic findings and his tenuous hemodynamic status, the decision was made to perform an angiography with potential embolization. The celiac artery was normal without sign of bleeding.

9. Opacification of the superior mesenteric artery showed a massive bleed in the pancreatico-duodenal branch .

11. Later phases demonstrated contrast filling of the duodenum .

13. The branch was selectively catheterized and microcoils were injected .

15. The embolization resulted in hemostasis .

17. The patient stabilized and was extubated three days later
The patient stabilized and was extubated three days later. A repeat endoscopy 24 h after embolization only demonstrated edema and mucosal friability in the descending portion of the duodenum.

18. Discussion:
This case highlights that angiography offers diagnostic and therapeutic options in patients with massive gastrointestinal bleeding that cannot be localized and treated endoscopically. While selective infusion of vasopressin may be effective in up to 50 %, it is less likely to achieve hemostasis in situations such as the one described above.

19. Embolization with microcoils or other material reportedly succeeds in more than 80 % of patients with massive gastrointestinal bleeding. While the exact etiology of the bleeding in this case remained unclear, the relatively normal endoscopic appearance of the duodenum on repeat endoscopy points at a Dieulafoy lesion, which are often seen distal of the stomach.

20. Despite the life threatening complication of this lesion, follow up studies indicate that no additional treatment is needed after the initial successful therapy.