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An 81-year-old woman was admitted to the intensive care unit with pneumonia complicated by acute kidney injury. Her medical history included arterial hypertension and chronic hepatitis B virus infection. The patient was on dual antiplatelet therapy because of recent myocardial infarction. Antibiotic treatment and continuous renal replacement therapy were started. Four days after admission, the patient’s condition improved and she was moved to the internal medicine unit. Two days later a hemodialysis session was required because of persistent metabolic acidosis, uremia, and hyperkalemia. A few hours later, she presented hypovolemic shock, with melena and a significant hemoglobin drop; coagulation tests were normal. Emergency endoscopy was performed, showing no hemorrhagic stigmata during intubation of the upper gastrointestinal tract (▶Fig. 1); however, a small amount of fresh blood and clots were aspirated from the third portion of the duodenum (▶Fig. 2; ▶Video 1). The third portion of the duodenum presented diffuse ulcerations affecting half of the antimesenteric portion of the circumference, while the mesenteric side was preserved. Interestingly, the second portion and the duodenal bulb showed only small erosions (▶Fig. 3). Surprisingly, despite a normal appearance during intubation, the gasE-Videos

NSAIDs-induced upper gastrointestinal bleeding in hepatitis B virus-positive patient with acute kidney injury – nonocclusive mesenteric ischemia