A 72-year-old male patient with a history of urothelial carcinoma treated with chemotherapy. During follow-up, a nonspecific hypodense nodular image measuring 26 mm was observed on CT scan at the posterior margin of the pancreatic head. Concurrent with this finding, the patient developed intermittent melena and anemia. Gastroscopy revealed a 20 mm excavated ulcer in the second portion of the duodenum, oozing blood in a sheet-like pattern, with an infiltrative appearance.

An endoscopic ultrasound was performed, revealing a 27 mm heterogeneous, rounded, hypoechoic lesion in the pancreatic head, adjacent to the papilla. Ultrasound visualization showed a duodenal ulcer embedded within the pancreatic lesion. A 22G biopsy needle was used to puncture the lesion, and the histopathological examination was suggestive of urothelial carcinoma metastasis. Following the endoscopic ultrasound examination, adrenaline was injected into the ulcer. At the end of the procedure, an adherent clot was observed without active bleeding. Based on these findings, the treatment was modified.

Gastrointestinal bleeding is an uncommon manifestation of pancreatic lesions that is usually associated with a poor prognosis and is refractory to endoscopic treatment. In our case, no further endoscopic treatments were necessary and no complications arose despite the puncture being performed through the infiltrative duodenal ulcer. Furthermore, although pancreatic metastases are becoming increasingly frequent, they remain a very uncommon site of metastasis for urothelial carcinoma; endoscopic ultrasound with biopsy is a fundamental tool for the proper management of these patients.