upper gastrointestinal bleeding is a common presentation in the usa with significant morbidity and mortality if not treated appropriately . the annual incidence of acute ugi bleeding is reported as 100 per 100 000 , with a mortality rate reported between 2.5 and 10% . in over 75% of cases , the bleeding is secondary to non - variceal causes . in the majority of cases , ulcers , erosions and esophagitis rupture of sa aneurysm or pseudoaneurysm , with visceral communication presenting as gastrointestinal bleeding is a very rare cause . if the patients ' hemodynamic status permits , preoperative diagnosis can be helpful to the surgeon in performing the optimal intervention for this condition . standard over - sewing of a  bleeding gastric ulcer would leave the patient 's underlying etiology untreated and almost certain to rebleed and needing repeat intervention . we report on the case of a frail 77-year - old multiparous patient who presented with a large gastric ulcer , which had eroded posteriorly causing a pseudoaneurysm of the sa and ultimate rupture , causing several episodes of ugi bleeding . she was successfully treated using a multidisciplinary approach of endoscopy , angiography and ultimately surgery . a frail 77-year - old multiparous caucasian female with a history of aspirin and naproxen use , presented to an outside hospital with epigastric pain and an episode of hematemesis . the patient was hemodynamically stable with an acute anemia ( hemoglobin of 7.7 g / dl ) , which prompted transfusion of 2 units of prbc and transfer to a tertiary care facility . upon transfer , she underwent an emergent upper endoscopy , which revealed a large amount of blood with clots in the lumen of the stomach . however , sufficient suctioning of the large intra - gastric clots was not possible ; hence , an underlying etiology was not obtainable . the patient subsequently underwent a diagnostic angiography , which revealed a 4 cm mid - sa pseudoaneurysm with active contrast extravasation into the stomach which can be seen in figs  1 and 2 . the radiologist decided to perform a transcatheter arterial coil embolization of the artery to halt the active bleeding . a planned upper endoscopy was repeated the following day that revealed some residual clotted blood in the stomach , no active bleeding and a deep 4 cm gastric ulcer . due to the high risk of re - bleeding , intraoperatively we observed that the sa pseudoaneurysm was densely adherent to the posterior wall of the stomach , and coursing through an inflamed distal pancreas . we decided to proceed with an en bloc resection of sa pseudoaneurysm , distal pancreatectomy , partial gastrectomy and splenectomy . after the celiac axis was surgically defined , proximal and distal sa controls were obtained and a circumferential posterior gastrotomy was made . there was a visible posterior gastric mucosa to splenic arterial fistula , with the radiologically inserted embolic coils clearly visible . once the stomach was reflected , the splenic vessels and the pancreas were divided and the specimen removed . the pathology reports indicated active gastritis with transmural ulceration into the splenic artery ( sa ) and adjacent pancreatic tissue . no malignant cells were identified in the gastric or pancreatic tissue and the sa was not aneurysmal ( fig .  5 ) . during the postoperative period , figure  3:surgical specimen of en bloc partial gastrectomy , distal pancreatectomy and splenectomy . embolic coils visible in arterial lumen . 
 figure  5:pathologic specimen  gastro  splenic artery fistula . splanchnic artery aneurysms are rare ; however , the sa is the most common site . aneurysmal erosion and rupture into surrounding structures causing bleeding into the lesser sac or hemoperitoneum , upper and lower gastrointestinal bleeding via fistulizing into the stomach and colon , respectively , and bleeding into the pancreatic duct ( hemosuccus pancreaticus ) have been previously described [ 35 ] . sa aneurysms can be found in all age groups with peaks in the fifth and sixth decades . eighty - seven percent of sa aneurysms are found in women and 80% are multiparous . sa pseudoaneurysms are even rarer than true aneurysms . it has been reported that pseudoaneurysms are always symptomatic unlike the majority of true aneurysms , which are usually asymptomatic . however , unlike true aneurysms , the size of the sa pseudoaneurysm is not a predictor of rupture . there are a number of etiologies for sa pseudoaneurysm including pancreatitis ( 52% ) , abdominal trauma ( 29% ) , postoperative complication ( 3% ) and peptic ulcer disease ( 2% ) . the incidences of presentation are : upper or lower gi bleed ( 26.2% ) , hemosuccus pancreaticus ( 20.3% ) , hematemesis ( 14.8% ) and with abdominal pain ( 29.5% ) . it appears that the true sa aneurysm causes pressure on surrounding viscera as it increases in size . during this time a fistulus connection is formed , and once it ruptures , it can present as gi bleeding . hence , the aneurysm is the causative element . however , in the case of an sa pseudoaneurysm , a pathology of the surrounding viscera leads to vessel wall contact with digestive gastric or pancreatic enzymes facilitating a fistula and resultant bleeding . in our case it appeared that the large gastric ulcer had eroded posteriorly into the pancreas and sa , causing a pseudoaneurysm and subsequent rupture . the fistula was clearly evident intraoperatively , with the embolic coils plainly visible through the stomach wall . it has been hypothesized that surgical management of ruptured aneurysms and pseudoaneurysms of the sa usually consist of splenectomy or splenopancreatectomy ; however , asymptomatic true aneurysms can be treated with splenopancreatic preservation . however , this may not represent adequate definitive management in a patient with an sa aneurysm or pseudoaneurysm with gi bleeding , as there is by definition a fistulus connection . it is unsurprising that there have been several reports of post procedural embolic coil migration . we believe that the presence of an sa pseudoaneurysm with gi bleeding can initially be diagnosed and managed using angiography and tae ; however , definitive surgery to remove the underlying etiology must be strongly considered to reduce future morbidity in surgically acceptable candidates . if the surgical risk is prohibitive , then close endoscopic surveillance should be conducted . gi bleeding secondary to visceral a high index of suspicion must be held , especially in patients with a history of pancreatitis . in the presence of hemodynamic stability . however , long - term prospective outcomes of this alone have not been published , and reports of complications , including coil migration , have been observed . hence definitive surgery must be considered to eradicate the underlying etiology and reduce further morbidity .
upper gastrointestinal ( ugi ) bleeding secondary to a ruptured splenic artery ( sa ) pseudoaneurysm into the stomach is a rare but a life - threatening condition . owing to the low prevalence 
 , it remains a diagnostic and therapeutic challenge . a frail 77-year - old caucasian female presented with epigastric pain and hematemesis . 
 endoscopy was non - diagnostic for an etiology . 
 she then underwent diagnostic angiography that revealed an sa pseudoaneurysm with active contrast extravasation into the stomach . 
 subsequent transcatheter arterial coil embolization was conducted of the sa . 
 the patient was subsequently taken for a partial gastrectomy , distal pancreatectomy and splenectomy . 
 she had an uncomplicated postoperative course.diagnosis of an ugi bleeding secondary to a ruptured sa pseudoaneurysm into the stomach remains difficult 
 . however , we report that in a hemodynamically stable patient , a multidisciplinary approach can be taken , with interval optimization of the patient prior to definitive surgery for a satisfactory outcome .