Image challenge: blood in duodenum

What caused blood in the papilla of Vater of a patient that presented with profound fatigue after a three-week-long alcohol bing?

Gastroenterology clinical image challenge: A 46-year-old man with a history of alcohol use disorder, a prior episode of hemorrhagic pancreatitis complicated by provoked pulmonary embolism status post anticoagulation presented with profound fatigue after a three-week-long alcohol binge. On arrival to the emergency department, he was hemodynamically stable. Physical examination was pertinent for conjunctival pallor and a soft abdomen that was nontender to palpation. Otherwise, his examination was within normal limits. Laboratory analysis was revealing for a hemoglobin of 2.9 g/dL, hematocrit of 11.9%, mean corpuscular volume of 71.7 fL and a platelet count of 557 k/μL. His basic metabolic panel demonstrated hyponatremia with a sodium of 126 mmol/L, a blood urea nitrogen of 10 mg/dL and a creatinine of 0.68 mg/dL. The patient previously had a baseline hemoglobin of 17.2 g/dL one year before the present admission. The patient had no evidence of hematemesis, melena, bright red bleeding per rectum or hematochezia during his hospitalization. He was appropriately resuscitated with blood products. To investigate his acute blood loss anemia, gastroenterology was consulted and esophagogastroduodenoscopy (EGD) was performed. The EGD was revealing for blood emanating from the area of the papilla of Vater (figure), but without brisk bleeding. He also had grade D esophagitis without evidence of recent bleed and an edematous stomach. Computed tomography angiography was performed.

What is this phenomenon called? What are the most common causes of this type of bleeding?

To find out the diagnosis, read the full case in Gastroenterology.

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