Refractory gastrointestinal bleeding caused by splenic artery pseudoaneurysm rupture

A 64-year-old man was admitted for hematemesis. Esophagogastroduodenoscopy revealed a gastric ulcer with a visible vessel on the posterior wall of the gastric body. After admission, the patient developed multiple episodes of massive hematemesis. During emergent esophagogastroduodenoscopy, he developed hemodynamic instability due to spurting bleeding. On day 18 of hospitalization, hemostasis was achieved using hemostatic forceps; however, contrast-enhanced computed tomography performed on the same day revealed a small splenic artery pseudoaneurysm (SAP) that had not been previously detected. To prevent fatal re-bleeding, interventional radiology was performed, and coil embolization was applied proximal to the pseudoaneurysm. The patient recovered without further hematemesis. One month later, exposed coils were observed from the healing ulcer, and celiac trunk angiography confirmed splenic artery thrombosis. Despite multiple attempts at endoscopic intervention, the patient developed recurrent hematemesis, suggesting that the gastric ulcer had eroded into the splenic artery, forming the SAP and causing significant hemorrhage. Although SAPs secondary to gastric ulcers are extremely rare, early recognition is critical because they carry a high risk of rupture and mortality. Endoscopic procedure alone may be insufficient, and an endovascular approach is a standard treatment to prevent life-threatening re-bleeding.