a 56-year - old man suffering from diabetes and hypertension was admitted to the neurology department in a hospital elsewhere with signs of epileptic seizure . after a brief period ,
a diagnostic laparotomy with gastrotomy was performed , at which over 3 liters of blood were found , but no active bleeding .
the site of origin of hemorrhage was suspected at the gastroesophageal junction , although no peptic ulcer could be discovered .
gastroscopy was performed 1 day later , demonstrating a large , ulcerating tumor at the cardia , of which biopsies were taken . because the patient was now diagnosed with a bleeding tumor at the gastroesophageal junction , he was transferred to the icu of the canisius - wilhelmina hospital in nijmegen ( in formation with the radboud university hospital comprising the esophagus centre eastern netherlands , scon ) .
a computed tomography ( ct ) scan was performed , showing a large tumor at the gastroesophageal junction , extending towards the pancreatic tail ( fig .
a second gastroscopy with new biopsies , 8 days later , proved the same results . at the time of the third gastroscopy ,
a second ct scan revealed a remarkable decline of the entire process , emanating from the pancreatic tail as a pseudocyst ( fig .
our patient experienced hypovolemic shock following massive gastrointestinal hemorrhage caused by a burst - through of a pancreatic pseudocyst to the stomach .
the incidence of upper gastrointestinal hemorrhage in the netherlands is 45 - 70 per 100,000 per year , most of which are caused by peptic ulcers of the stomach and duodenum .
a pseudocyst of the pancreas consists of one or several collections of pancreatic fluid , surrounded by inflamed pancreatic tissues .
the wall is formed by the enclosing structures , i.e. stomach , transverse colon or omentum . the pseudocyst is usually connected to the pancreatic duct .
the distinctive feature between a genuine cyst and a pseudocyst is the lack of an epithelial layer .
pseudocysts of the pancreas arise as a result of episodes of acute pancreatitis or blunt force abdominal trauma .
the cause is often disruption or obstruction of the pancreatic duct , with subsequent accumulation of pancreatic fluids , containing high concentrations of pancreatic enzymes . in acute pancreatitis , ( pseudo)cyst and necrosis
can be difficult to distinguish by contrast - enhanced ct scan , whereas magnetic resonance imaging ( mri ) is distinctive .
pseudocysts can damage adjacent arteries by means of mechanical pressure and digestion by pancreatic enzymes , hereby causing the formation of pseudoaneurysm with possible subsequent hemorrhage into the pancreatic duct .
usually , this involves the splenic artery , but also the gastroepiploic arteries and gastroduodenal branches can be affected .
the old motto is to drain pseudocysts larger than 6 cm or existing longer than 6 weeks , although literature on the subject scarcely supports this .
the possibilities for drainage are to marsupialize the pseudocyst through laparotomy or laparoscopy to the stomach or jejunum , or to perform resection of the pancreatic tail
pseudoaneurysms or hemorrhages are eligible for endovascular embolization , and transgastric drainage of cysts is contraindicated during hemorrhages , unless embolization is performed first .
case series and case reports in the available literature on hemorrhaging pseudocysts all advocate endovascular embolization , followed by resection of the pancreatic tail [ 5 , 8 , 9 , 10 , 11 , 12 , 13 ] . our patient was diagnosed with hemorrhaging pseudocyst 16 days after admission and initial laparotomy .
because of the improving clinical condition and decline of the pseudocyst on ct scan , it was decided to pursue a 
the initial plan was to perform pancreatic tail resection after clinical recovery ; however , ultrasonography and ct scan revealed a rapid decline and full disappearance of the pseudocyst .
our patient made a full recovery and has adjusted his life style . in all case reports ,
operative intervention is advocated , precipitated by endovascular embolization in case of serious hemodynamic instability .
one case series of 16 patients reports a 62% mortality rate , in which endovascular embolization is combined with pancreatic tail resection .
there is evidence to support the role of angiography in case of acute upper gastrointestinal hemorrhage , simultaneously offering the possibility for endovascular treatment [ 2 , 5 , 8 , 9 , 10 , 11 , 12 , 13 ] .
embolizing the splenic artery does not inevitably necessitate splenectomy , for the remaining blood supply to the spleen is routed through the vasa brevia , which should be sufficient .
furthermore , the course of our patient proves that surgical intervention such as pancreatic tail resection is not always an absolute necessity .
however , surgery is nowadays not the only option for treatment , as possibilities in radiological endovascular diagnostics and techniques are increasing and will eventually be the first step in treating acute upper gastrointestinal hemorrhage .
 acute upper gastrointestinal tract hemorrhage represents a frequent morbidity which can be localized and treated endoscopically . when endoscopic treatment alone is failing , radiological or surgical treatment may be warranted . 
 a case history will be presented regarding a rare cause of intestinal hemorrhage with an extraordinary course of illness . 
Case Report
Discussion
Conclusion