A Hidden Source for Upper Gastrointestinal Bleeding

* Corresponding Author: Maryam Moini, MD Gastroenterology and Hepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Telefax: + 98 711 6473236 Email: [email protected] Received: 10 Jan. 2013 Accepted: 11 Mar. 2013 A 50-year-old lady presented with bloody vomiting and melena since four days prior to admission. Her medical history was significant only for hypertension which was controlled by a 5 mg daily dose of amlodipine. She occasionally took NSAIDs. On admission, the physical exam revealed only mild tachycardia and pallor. Hemoglobin was 9.7 g/dl, which subsequently declined to 7.9 g/dl. The first upper gastrointestinal (GI) endoscopy was remarkable for a paraesophageal hiatal hernia, with no site of bleeding detected. The second upper GI endoscopy did not find any source for bleeding. A third endoscopic examination revealed a new finding (Figures A and B). What’s your diagnosis? 112