Case Presentation and EvolutionA 26-year-old man presented to a local emergency department with hematemesis and melena associated with mild mid-epigastric abdominal discomfort and light-headedness. He had no prior history of gastrointestinal (GI) bleeding, but he recalled having as a young child, up to 10 years of age, intermittent self-limited attacks of crampy abdominal pain that were never severe enough to prompt evaluation. He had no other significant medical history. His past surgical history was notable only for skull surgery as an infant. He took no medications on a regular basis, and used non-steroidal anti-inflammatory drugs infrequently. From 18 to 21 years of age, he indulged in heavy alcohol use but currently had only 3-4 drinks per week. On presentation, his hemoglobin was 13.7 g/dl and his blood urea nitrogen 29 mg/dl; otherwise, his laboratory values were unremarkable. An esophagogastroduodenoscopy (EGD) to the second portion of the duodenum reportedly showed mild gastritis and no esophageal varices. He was sent home on a proton-pump inhibitor after he was observed 24 h without further GI bleeding.Within 12 h of discharge from the emergency department, he experienced recurrent melena and light-headedness. On return to the hospital, he had tachycardia, his hemoglobin had dropped to 7.3 g/dl, and his blood urea nitrogen was now 36 mg/dl. He was resuscitated with four units of packed red blood cells. A computed tomography (CT) scan of the abdomen revealed a vascular abnormality of the superior mesenteric vein (SMV) with possible intestinal malrotation. The patient was transferred to our center for further evaluation and possible intervention.On admission, his post-transfusion hemoglobin was 10.1 g/dl, and he was experiencing no further GI bleeding. A triphasic CT scan was obtained to further characterize the lesion noted on the previous CT scan (Fig. 1). In the third portion of the duodenum, an enhancing lobulated structure was seen draining into a large vein. Radiographically, this structure appeared to be a varix, but a hypervascular mass remained in the differential diagnosis. ''Swirling'' of the SMV around the superior mesenteric artery was noted to be consistent with intestinal malrotation. A short segment of the superior mesenteric artery (SMA) was thrombosed with reconstitution distally. There was no evidence of ischemic bowel. No other varices were noted.As the patient was clinically stable, an EGD with endoscopic ultrasound (EUS) was performed and it revealed a raised structure in the third portion of the duodenum with normal overlying mucosa (Fig. 2a). EUS revealed the underlying structure to be hypervascular, most consistent with a vascular malformation (Fig. 2b). At the apex of the lesion there was a small ulcerative defect (arrow), which was the likely source of bleeding.