Posterior nasal hemorrhage mimicking intra-abdominal hemorrhage after gastrectomy: a case report.

Background: Postoperative hemorrhage is a serious complication following gastrectomy, most commonly resulting from anastomotic bleeding or pseudoaneurysm rupture. When conventional diagnostic modalities fail to identify the source of bleeding, establishing an accurate diagnosis can be extremely challenging. Case presentation: We report the case of a 77-year-old Asian woman diagnosed with gastric malignancy who underwent Roux-en-Y total gastrectomy in our department. On postoperative day 6, she developed an esophagojejunal anastomotic leak. On postoperative day 28, the patient experienced hemorrhage, with bright red blood draining from the abdominal drain, mimicking delayed extra-intestinal bleeding. However, abdominal computed tomography (CT), endoscopy, and digital subtraction angiography (DSA) revealed no evidence of intra-abdominal hemorrhage. Endoscopic evaluation further demonstrated that the abdominal drain had migrated into the jejunal lumen through the anastomotic leak. Ultimately, nasendoscopy identified the true source of bleeding: the posterior nasal cavity. Blood from this site entered the digestive tract via the pharynx and was externally drained through the displaced abdominal drain. Hemostasis was successfully achieved using endoscopic electrocautery. Conclusion: In cases of post-gastrectomy hemorrhage where contrast-enhanced CT, endoscopy, and DSA fail to localize the bleeding source, clinicians should actively investigate for remote or occult bleeding sites and consider atypical drainage pathways.