Figure 1
Teaching Case
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsMatteoli Marco, Tesei Jacopo, Rossi Michele, David Vincenzo
Connected authors
45 years, male
A 45-year-old male patient presented with a sudden onset of epigastric pain and progressive asthenia. He was quite pale, tachycardic (HF 126 bpm), normocitic and normochromic anemia (Hb 7g/dl, MCV 80fl), serum amylase 180 IU/l. Alcohol intake 5-6U/day for 20 years. Smoker (30PY). A digital rectal examination revealed melena.
Pancreatic pseudocyst, fistuled with a pseudoaneurysm of a ramus of left gastric artery.
Pseudoaneurysm
Gastric cancer
Pancreatic cancer
A digestive endoscopy showed a neoformation of the posterior gastric wall (Fig. 1), with a focal and bleeding corrosion in the central region.
A 16-Row MDCT imaging of abdomen showed a pseudo-nodular injury (43 x 28mm) at the pancreatic tail, with a mild compression against the lesser gastric curvature, and a slightly hyperdense appearance at basal images, with slow filling after administration of contrast medium, most evident in the venous phase (Fig. 2a-b).
The slight inhomogeneity of pancreatic tail and irregular appearance of the duct of Wirsung gave evidence for chronic pancreatitis (Fig. 2c). Digestive haemorrhage was secondary to corrosion of the gastric wall by a pancreatic pseudocyst, fistuled with a pseudoaneurysm of an unspecified peripancreatic vessel. A superselective angiogram of left gastric artery showed the position of the pseudoaneurysm and signs of active bleeding (Fig. 3). Embolization procedure was performed by an injection of spongostan at his afference (Fig3c).
A 16-Row MDCT imaging of abdomen showed a pseudo-nodular injury (43 x 28mm) at the pancreatic tail, with a mild compression against the lesser gastric curvature, and a slightly hyperdense appearance at basal images, with slow filling after administration of contrast medium, most evident in the venous phase (Fig. 2a-b).
The slight inhomogeneity of pancreatic tail and irregular appearance of the duct of Wirsung gave evidence for chronic pancreatitis (Fig. 2c). Digestive haemorrhage was secondary to corrosion of the gastric wall by a pancreatic pseudocyst, fistuled with a pseudoaneurysm of an unspecified peripancreatic vessel. A superselective angiogram of left gastric artery showed the position of the pseudoaneurysm and signs of active bleeding (Fig. 3). Embolization procedure was performed by an injection of spongostan at his afference (Fig3c).
Major haemorrhages are a rare but lethal complication of pancreatitis, usually due to a rupture of pseudoaneurysms of a peripancreatic artery [1, 9]. Splenic, gastroduodenal and pancreaticoduodenal arteries are the commonly involved vessels. Left gastric artery is the less common [2].
To define the peripancreatic vessel, and to treat the pseudoaneurysm [3], an angiographic imaging and treatment were performed (Fig. 3), that in the haemodynamically stable patient, is a procedure that gives the best results in 67-100% of the cases [4-5].
The CT examination after embolization showed no evidence of the hyperdensity within the collection situated at the pancreatic tail, as a correct outcome of the procedure (Fig. 4a-b). Angiography is the gold standard to reveal pseudoaneurysms, however, CT examination is the best method to identify this atypical location [6] and the presence of pseudocysts, a localized collection of pancreatic fluid surrounded by granulation tissue and collagen [7], with a morphology of a located fluid collection with a peripheral enhancement (Fig 4a-b) [4].
Althought the embolization procedure of the neck preserves the flow along the artery, the risk of laceration secondary the infusion of embolisation material inside the aneurysm is very high [8]. In this case, spongostan was used as a closure device for the aneurysm, putting it only at the proximal region, because the distal zone was not available, and this kind of matherial was chosen to reduce the risks of ischaemia of the medial portion of the stomach, due to a complete obliteration of the left gastric artery. This approach provides the possibility to let the aneurysm coagulate and to resolve the bleeding, sparing the flow of the left gastric artery.
To define the peripancreatic vessel, and to treat the pseudoaneurysm [3], an angiographic imaging and treatment were performed (Fig. 3), that in the haemodynamically stable patient, is a procedure that gives the best results in 67-100% of the cases [4-5].
The CT examination after embolization showed no evidence of the hyperdensity within the collection situated at the pancreatic tail, as a correct outcome of the procedure (Fig. 4a-b). Angiography is the gold standard to reveal pseudoaneurysms, however, CT examination is the best method to identify this atypical location [6] and the presence of pseudocysts, a localized collection of pancreatic fluid surrounded by granulation tissue and collagen [7], with a morphology of a located fluid collection with a peripheral enhancement (Fig 4a-b) [4].
Althought the embolization procedure of the neck preserves the flow along the artery, the risk of laceration secondary the infusion of embolisation material inside the aneurysm is very high [8]. In this case, spongostan was used as a closure device for the aneurysm, putting it only at the proximal region, because the distal zone was not available, and this kind of matherial was chosen to reduce the risks of ischaemia of the medial portion of the stomach, due to a complete obliteration of the left gastric artery. This approach provides the possibility to let the aneurysm coagulate and to resolve the bleeding, sparing the flow of the left gastric artery.
References
[1] Maus TP (1993) Pseudoaneurysm haemorrhage as a complication of pancreatitis. Mayo Clin Proc 68:895-6 (PMID: 8371607)
[2] Honoré C, Bruyère PJ, Maweja S, Meunier P, Meurisse M, Defraigne ((200) Pseudoaneurysm of the left gastric artery. J Chir (Paris) Aug 146(4):413-5 (PMID: 19640530)
[3] Burke JW, Erickson SJ, Kellum CD, Tegtmeyer CJ, Williamson BRJ, Hansen MF. (1986) Pseudoaneurysms complicating chronic pancreatitis: detection with CT. Radiology 161:447-50. (PMID: 3763917)
[4] Gambiez LP, Ernst OJ, Merlier OA, Porte HL, Chambon JP, Quandalle PA. (1997) terial embolization for bleeding pseudocysts complicating chronic pancreatitis. Arch Surg 132:1016-21 (PMID: 9301616)
[5] Boudghene F, L`Hermine C, Bigot JM. (1993) Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol 4:551-8 (PMID: 8353353)
[6] Negi SS, Sachdev AK, Bhojwani R, Singh S, Kumar N. (2002) Experience of surgical management of pseudo-aneurysms of branches of the coeliac axis in a North Indian Hospital. Trop Gastroenterol Apr-Jun;23(2):97-100 (PMID: 12632981)
[7] Byrne MF, Mitchell RM, Baillie J. (2002) Pancreatic Pseudocysts. Curr Treat Options Gastroenterol Oct;5(5):331-338. (PMID: 12207856)
[8] Ikeda O, Nakasone Y, Tamura Y, Yamashita Y. (2010) Endovascular management of visceral artery pseudoaneurysms: transcatheter coil embolization using the isolation technique. Cardiovasc Intervent Radiol Dec;33(6):1128-34 (PMID: 20857110)
[9] Carr JA, Cho JS, Shepard AD, Nypaver TJ, Reddy DJ. (2000) Visceral pseudoaneurysms due to pancreatic pseudocysts: rare but lethal complications of pancreatitis. J Vasc Surg Oct;32(4):722-30 (PMID: 11013036)
Case information
| URL: | https://eurorad.org/case/10271 |
| DOI: | 10.1594/EURORAD/CASE.10271 |
| ISSN: | 1563-4086 |
Figure 2
Department of Gatroenterology, San Filippo Neri, Rome
Figure 3
Department of Radiology, Sant\'Andrea Hospital, II Faculty of medicine \"La Sapienza, Roma, Italy;
Department of Radiology, Sant\'Andrea Hospital, II Faculty of medicine \"La Sapienza, Roma, Italy;
Department of Radiology, Sant\'Andrea Hospital, II Faculty of medicine \"La Sapienza, Roma, Italy;
