S4716 A Rare Double Complication: Gastroduodenal Artery Pseudoaneurysm and Intraductal Air Secondary to Duodenal Ulcer Without Pancreatitis

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Introduction: Duodenal ulcers are common gastrointestinal lesions typically associated with Helicobacter pylori infection or chronic nonsteroidal anti-inflammatory drug (NSAID) use. While bleeding and perforation are well-known complications, vascular involvement such as gastroduodenal artery (GDA) pseudoaneurysm is rare, especially in the absence of pancreatitis. Additionally, intraductal air in the pancreatic duct is an uncommon radiologic finding, usually linked to trauma, instrumentation, fistula, or malignancy. We describe a rare case of a duodenal ulcer complicated by both GDA pseudoaneurysm and intraductal air, without evidence of pancreatitis, malignancy, or prior intervention. Case Description/Methods: An 82-year-old woman with chronic NSAID use for back pain presented with sudden-onset epigastric pain. She was hemodynamically stable, but labs showed a hemoglobin of 6.7 g/dL, down from 8.0 g/dL the prior week. Computed tomography of the abdomen and pelvis revealed duodenitis and intraductal air, later confirmed by magnetic resonance cholangiopancreatography (MRCP) without obstruction or mass. She received intravenous proton pump inhibitors and 2 units of packed red blood cells. Esophagogastroduodenoscopy (EGD) showed a duodenal bulb ulcer with an adherent clot treated with argon plasma coagulation (APC), and multiple oozing ulcers in the second portion of the duodenum treated with epinephrine injection, APC, and hemostatic spray. Post-procedure, she developed melena and hemodynamic instability, requiring additional transfusions. Computed tomography angiography (CTA) revealed a new GDA pseudoaneurysm, likely from ulcer erosion. Embolization was performed successfully, and her condition stabilized. Repeat imaging showed no active bleeding. She was discharged in stable condition with plans for outpatient follow-up and repeat MRCP. Discussion: GDA pseudoaneurysms are rare and typically associated with chronic pancreatitis. In this case, there was no history or imaging evidence of pancreatitis, and prior scans showed no vascular abnormalities. The pseudoaneurysm likely resulted from ulcer-related erosion and adjacent inflammation. Intraductal air was present without biliary involvement, raising concern for mucosal breach or direct ulcer penetration. Although pancreatic malignancy is a differential in such cases, it was not supported by MRCP or endoscopic findings. This case highlights the need to consider rare vascular and structural complications in duodenal ulcers with atypical imaging features.

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