Abdominal examination showed a midline scar and bulge in the epigastric region
that was soft and nontender on palpation.
There was tenderness and defense on palpation of epigastric region
. Rebound was not present and bowel sounds were normoactive.
Abdominal examination revealed mild tenderness in epigastric region
without peritoneal signs.
The larger one was approximately 3.5x2.0cm, and it was located in the right epigastric region
over the last three ribs in a ventral-dorsal projection.
There was a palpable mass in the abdomen at the epigastric region
, the umbilical region and the left flank.
Physical examination revealed tenderness of the epigastric region
and the upper right quadrant, with diffuse flushing of the skin.
At clinical examination, a vascular sound could be heard in the epigastric region
Abdominal pain is seen only in 35%patients, whereas gastrointestinal bleeding is present in 94% and pulsatile mass in 25% patients.5 This is a characteristic picture of herald bleeding which is a result of a small fistula tamponaded by thrombus formation.7 Other symptoms may include intermittent back pain, fever, sepsis, melena, weight loss, and syncope.4,7 The patient in the current case presented with lower GI bleeding and a painless pulsating mass in epigastric region
. The most valuable tool for diagnosis of PAEF is a contrast-enhanced CT scan abdomen, which has a detection rate of 61%.2,3,5 It has a high sensitivity for PAEF.
However, the abdominal ultrasound showed a voluminous (18 Eu 10 cm) heterogeneous mass located in the epigastric region
in front of the pancreas and pushing the left liver lobe anteriorly and laterally.
In 52% (n=104), the pain started in the RIF while in 48% (n=96) patients, the pain started in the umbilical or epigastric region
and latter migrated to the RIF.
On examination, there was tenderness in epigastric region
and right hypochondrium.