a 55-year - old man presented at our emergency department with sudden - onset sharp chest pain that had started two hours previously .
he also complained of progressive swelling and bruising on his neck , and the development of dysphagia and dyspnea over the previous two hours .
he had a history of admission with spontaneous hemothorax seven years previously , and at that time , despite several work - ups for hemothorax , its origin was not found .
other than this incident , he had hypertension but no history of gastrointestinal or bleeding disorders . upon arrival at the emergency department
extensive neck swelling was observed , as well as bruising on the neck and upper chest . during the examination
, he suddenly vomited bright red blood with food material three times , and approximately a quarter - cup of blood was generated on each occasion .
other laboratory tests , including cardiac markers and his coagulation profile , were within their normal ranges .
1b ) revealed extensive non - enhancing soft tissue lesions in the posterior mediastinum and neck , which were suspected to be hematomas .
emergency gastroscopy showed many blood clots but no definite focus of gastrointestinal bleeding , such as an ulcer , mass , or perforation . instead , gastroscopy showed extrinsic esophageal compression .
since the patient was hemodynamically stable , conservative management was adopted in the intensive care unit .
followup ct on the third day post - admission showed a focal aneurysm in the right bronchointercostal trunk ( fig .
subsequent selective bronchial arteriography revealed a 1-cm aneurysm in the right bronchial artery ( fig .
since the aneurysm was considered to be the cause of the hematemesis and mediastinal hemorrhage , we decided to perform embolization to prevent recurrence .
the right bronchial artery was subsequently embolized with four microcoils ( vortx-18 ; boston scientific co. , marlborough , ma , usa ) and 33% glue ( fig .
2c ) , and repeat ct showed that the mediastinal hematoma had nearly disappeared ( fig .
the patient was discharged without complications . over the course of one year of follow - up
spontaneous mediastinal hemorrhage can develop as a result of trauma , aortic dissection , the valsalva maneuver , or iatrogenic procedures .
the rupture of a bronchial artery aneurysm ( baa ) is also known to result in mediastinal hemorrhage .
when a baa ruptures into the mediastinum , most patients present with chest pain , hemothorax , or hemomediastinum .
furthermore , if hematemesis is a prominent symptom of baa rupture , it can be confused with boerhaave s syndrome , variceal disease , or a perforated ulcer . to the best of our knowledge ,
only three cases of baa presenting with hematemesis have been reported in the literature [ 46 ] . in one case ,
a pinhole connection between the aneurysm and esophagus was found during an endoscopic examination , but in the present case , no evidence of communication was found between the aneurysm and the esophagus .
we first suspected that the mediastinal hemorrhage and hematemesis were caused by the perforation of an esophageal ulcer , but repeated gastroscopy showed a normal esophagus .
the only abnormal finding was the finding of a baa without evidence of extravasation three days after the onset of symptoms .
after ruling out the possibility of mediastinal hematoma , the baa was the only remaining possible source of the mediastinal hemorrhage . since the baa was regarded as the source of the mediastinal hemorrhage and hematemesis , it was embolized to avoid recurrence .
the treatment of a ruptured baa depends on the patient s hemodynamic status and the presence of cardiorespiratory compromise .
if the patient is hemodynamically stable , endovascular embolization is considered to be the first - line management strategy , and surgery should only be considered when embolization is contraindicated , as in patients allergic to contrast medium or when a medullary artery is involved . in patients presenting at an emergency department with hematemesis and mediastinal hemorrhage ,
 hematemesis is a rare manifestation of a ruptured bronchial artery aneurysm ( baa ) in the mediastinum . 
 it is difficult to diagnose a ruptured baa presenting as hematemesis , because it can be confused with other diseases , such as boerhaave s syndrome , variceal disease , or a perforated ulcer . in this report 
 , we describe a case of baa resulting in hematemesis and mediastinal hemorrhage . 
CASE REPORT
DISCUSSION