PMC5348597_01
a) CT abdomen in coronal view shows thickened duodenal wall with surrounding edema, consistent with duodenitis. Pancreatic head appears normal. b) Mesenteric angiogram shows superior mesenteric artery being filled with contrast. There is coil embolization of the inferior pancreaticoduodenal arcade and gastroduodenal artery. Multiple endoscopic clips are seen in the duodenum. Cholecystectomy surgical clips are additionally seen in the right upper quadrant.
gr1.jpg
PMC5348597_01_gr1.jpg
fig0005
IR embolization of the gastroduodenal artery and multiple branches of the superior and inferior pancreaticoduodenal arteries also failed to control bleeding (Fig. 1, Fig. 2, Fig. 3 ).
a) Follow-up abdominal aortogram shows contrast blush in the duodenum despite coil embolization of the gastroduodenal artery. b) Follow-up mesenteric angiogram shows filling of pancreaticoduodenal arcades despite coil embolization of some branches. Active extravasation from several small branches continues to be present in proximal duodenum adjacent to endoscopic clip.
gr3.jpg
PMC5348597_01_gr3.jpg
fig0015
IR embolization of the gastroduodenal artery and multiple branches of the superior and inferior pancreaticoduodenal arteries also failed to control bleeding (Fig. 1, Fig. 2, Fig. 3 ).
a) Duodenal ulcer abutting Brunner's glands (haematoxylin and eosin; 100X). b) Mucin-secreting epithelial cell in a Brunner's gland with viral cytopathic changes in keeping with CMV infection including an eosinophilic intranuclear inclusion and amphophilic finely granular intracytoplasmic inclusions (arrow, haematoxylin and eosin; 400X). Inset: CMV immunostain highlights both intranuclear and cytoplasmic inclusions in three epithelial cells (400X).
gr4.jpg
PMC5348597_01_gr4.jpg
fig0020
Histologic sections from an ulcer revealed viral cytopathic changes in keeping with CMV (Fig. 4a and b). Immunohistochemical stains for CMV were positive in both the duodenum and pancreas (see insets of Figs. 4 b and 5 b).
a) Pancreas with patchy severe necrotizing acute pancreatitis. Note the Islet of Langerhans in the upper left hand corner abutting pancreatic acinar cells (haematoxylin and eosin; 200X). b) An epithelial cell with an eosinophilic intranuclear viral inclusion (arrow) in keeping with CMV (haematoxylin and eosin; 400X). Inset: CMV immunostain highlights intranuclear inclusions in two epithelial cells (400X).
gr5.jpg
PMC5348597_01_gr5.jpg
fig0025
Sections from the pancreas showed patchy panlobular coagulative necrosis (Fig. 5a). Notably, ductal epithelial cells had viral cytopathic changes, which were also in keeping with CMV (Fig. 5b). Immunohistochemical stains for CMV were positive in both the duodenum and pancreas (see insets of Figs. 4 b and 5 b).