We report this case of a 74-year-old man with altered anatomy secondary to Billroth-II surgery who underwent endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis and subsequently developed severe diffuse abdominal pain with drop in hemoglobin. Patient was found to have hemorrhagic shock requiring aggressive resuscitative measures. Patient was found to have large peripancreatic hematoma secondary to bleeding from gastroduodenal and superior pancreaticoduodenal artery pseudoaneurysms. Gastroduodenal artery aneurysm is the rarest of all the splanchnic artery aneurysms, and to our knowledge this is the only reported case of a gastroduodenal artery pseudoaneurysm complicating ERCP. 1. Introduction Visceral artery aneurysms (VAAs) are a variegated group of conditions with a wide range of manifestations and prognostic significance. While true aneurysms result from intrinsic vessel wall defects, pseudoaneurysms are often precipitated by underlying traumatic or inflammatory etiologies such as pancreatitis, vascular or laparoscopic interventions, and rarely even liver transplantation [1, 2]. Pancreaticoduodenal and gastroduodenal artery aneurysms together account for only 3.5% of all VAA [3]. Pancreatitis is reported to be the inciting agent in almost half of the cases [3, 4]. However, post-ERCP pancreatitis has not been implicated before, in the formation of these aneurysms. 2. Case Report A 74-year-old Hispanic man, who was born and raised in Dominican Republic, first presented to the gastroenterology clinic with complaints of epigastric and right upper quadrant abdominal pain. Physical examination at the time was unremarkable. Laboratory studies showed abnormal liver enzymes (alanine transaminase of 108？IU/L, aspartate transaminase of 87？IU/L, and normal alkaline phosphatase of 118？IU/L with normal bilirubin levels). Review of prior abdominal imaging from an outside facility revealed dilated common bile duct (CBD) of 1.5？cm. Patient was known to have Hepatitis C without cirrhosis and had failed treatment for it before. Patient had prior cholecystectomy for symptomatic cholelithiasis and Billroth-II surgery for complicated gastric ulcers. A magnetic resonance cholangiopancreatography (MRCP) done for the evaluation of dilated CBD revealed a large ( ) stone in the distal CBD (Figure 1). Patient was scheduled for an elective ERCP for stone removal. Figure 1: MRCP revealed dilated CBD with a large ( ) stone in the distal part. During ERCP, the pancreatic duct was cannulated once, but CBD could not be cannulated in view of altered anatomy
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