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Massive Upper Gastrointestinal Bleeding from a Splenic Artery Pseudoaneurysm Caused by a Penetrating Gastric Ulcer: Case Report and Review of Literature.

Sawicki M, Marlicz W, Czapla N, Łokaj M, Skoczylas MM, Donotek M, Kołaczyk K - Pol J Radiol (2015)

Bottom Line: After negative results of endoscopy and ultrasound, the diagnosis was established in CT angiography.The successful treatment consisted of surgical ligation of the bleeding vessel and suture of the ulcer with preservation of the spleen and pancreas, which is rarely tried in such situations.In such cases, immediate CT angiography is useful in establishing diagnosis and in application of proper therapy before possible recurrence.

View Article: PubMed Central - PubMed

Affiliation: Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University, Szczecin, Poland.

ABSTRACT

Background: Splenic artery aneurysm and pseudoaneurysm are rare pathologies. True aneurysms are usually asymptomatic. Aneurysm rupture occurring in 2-3% of cases results in bleeding into the lesser sack, peritoneal space or adjacent organs typically presenting as abdominal pain and hemodynamic instability. In contrast, pseudoaneurysms are nearly always symptomatic carrying a high risk of rupture of 37-47% and mortality rate of 90% if untreated. Therefore, prompt diagnosis and treatment are essential in the management of patients with splenic artery pseudoaneurysm. Typical causes include pancreatitis and trauma. Rarely, the rupture of a pseudoaneurysm presents as upper gastrointestinal (UGI) bleeding. Among causes, peptic ulcer is the casuistic one.

Case report: This report describes a very rare case of recurrent UGI bleeding from a splenic artery pseudoaneurysm caused by a penetrating gastric ulcer. After negative results of endoscopy and ultrasound, the diagnosis was established in CT angiography. The successful treatment consisted of surgical ligation of the bleeding vessel and suture of the ulcer with preservation of the spleen and pancreas, which is rarely tried in such situations.

Conclusions: The most important factor in identifying a ruptured splenic artery pseudoaneurysm as a source of GI bleeding is considering the diagnosis. UGI hemorrhage from splenic artery pseudoaneurysm can have a relapsing course providing false negative results of endoscopy and ultrasound if performed between episodes of active bleeding. In such cases, immediate CT angiography is useful in establishing diagnosis and in application of proper therapy before possible recurrence.

No MeSH data available.


Related in: MedlinePlus

CT angiography: (A) A 5-mm oblique MPR shows the splenic artery pseudoaneurysm (arrow) on the posterior wall of the stomach with intragastric bleeding (arrowhead); (B) VRT reconstruction presents critical stenosis of the celiac artery (arrow); (C) VRT in coronal projection shows the ruptured pseudoaneurysm (arrow) with collaterals through the pancreaticoduodenal (arrowheads) and gastroepiploic arteries (empty arrow).
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f1-poljradiol-80-384: CT angiography: (A) A 5-mm oblique MPR shows the splenic artery pseudoaneurysm (arrow) on the posterior wall of the stomach with intragastric bleeding (arrowhead); (B) VRT reconstruction presents critical stenosis of the celiac artery (arrow); (C) VRT in coronal projection shows the ruptured pseudoaneurysm (arrow) with collaterals through the pancreaticoduodenal (arrowheads) and gastroepiploic arteries (empty arrow).

Mentions: During the next two days the patient improved significantly. He was normotensive with hemoglobin level of 10.6 g/dL. On the fourth day morning he was eager to be discharged. However, after an hour he suddenly collapsed. His BP was 75/50 mmHg and hemoglobin dropped to 9.3 g/dL. In order to localize the source of bleeding, emergent CT angiography was carried out (Figure 1). The key finding was the presence of massive intragastric bleeding from a ruptured distal splenic artery pseudoaneurysm. Contrast extravasation into the stomach was observed, indicating an active hemorrhage. Pseudoaneurysm with a diameter of 0.6 cm was localized on the posterior wall of the stomach in proximity to the cardia and surrounded by a thrombus. Erosion of an adjacent wall of the stomach was visible with necrotic masses filling a 4.0-cm ulcer crater. Additionally, critical stenosis of the celiac artery was found with collateral supply through the pancreaticoduodenal, short gastric and gastroepiploic arteries.


Massive Upper Gastrointestinal Bleeding from a Splenic Artery Pseudoaneurysm Caused by a Penetrating Gastric Ulcer: Case Report and Review of Literature.

Sawicki M, Marlicz W, Czapla N, Łokaj M, Skoczylas MM, Donotek M, Kołaczyk K - Pol J Radiol (2015)

CT angiography: (A) A 5-mm oblique MPR shows the splenic artery pseudoaneurysm (arrow) on the posterior wall of the stomach with intragastric bleeding (arrowhead); (B) VRT reconstruction presents critical stenosis of the celiac artery (arrow); (C) VRT in coronal projection shows the ruptured pseudoaneurysm (arrow) with collaterals through the pancreaticoduodenal (arrowheads) and gastroepiploic arteries (empty arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4538884&req=5

f1-poljradiol-80-384: CT angiography: (A) A 5-mm oblique MPR shows the splenic artery pseudoaneurysm (arrow) on the posterior wall of the stomach with intragastric bleeding (arrowhead); (B) VRT reconstruction presents critical stenosis of the celiac artery (arrow); (C) VRT in coronal projection shows the ruptured pseudoaneurysm (arrow) with collaterals through the pancreaticoduodenal (arrowheads) and gastroepiploic arteries (empty arrow).
Mentions: During the next two days the patient improved significantly. He was normotensive with hemoglobin level of 10.6 g/dL. On the fourth day morning he was eager to be discharged. However, after an hour he suddenly collapsed. His BP was 75/50 mmHg and hemoglobin dropped to 9.3 g/dL. In order to localize the source of bleeding, emergent CT angiography was carried out (Figure 1). The key finding was the presence of massive intragastric bleeding from a ruptured distal splenic artery pseudoaneurysm. Contrast extravasation into the stomach was observed, indicating an active hemorrhage. Pseudoaneurysm with a diameter of 0.6 cm was localized on the posterior wall of the stomach in proximity to the cardia and surrounded by a thrombus. Erosion of an adjacent wall of the stomach was visible with necrotic masses filling a 4.0-cm ulcer crater. Additionally, critical stenosis of the celiac artery was found with collateral supply through the pancreaticoduodenal, short gastric and gastroepiploic arteries.

Bottom Line: After negative results of endoscopy and ultrasound, the diagnosis was established in CT angiography.The successful treatment consisted of surgical ligation of the bleeding vessel and suture of the ulcer with preservation of the spleen and pancreas, which is rarely tried in such situations.In such cases, immediate CT angiography is useful in establishing diagnosis and in application of proper therapy before possible recurrence.

View Article: PubMed Central - PubMed

Affiliation: Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University, Szczecin, Poland.

ABSTRACT

Background: Splenic artery aneurysm and pseudoaneurysm are rare pathologies. True aneurysms are usually asymptomatic. Aneurysm rupture occurring in 2-3% of cases results in bleeding into the lesser sack, peritoneal space or adjacent organs typically presenting as abdominal pain and hemodynamic instability. In contrast, pseudoaneurysms are nearly always symptomatic carrying a high risk of rupture of 37-47% and mortality rate of 90% if untreated. Therefore, prompt diagnosis and treatment are essential in the management of patients with splenic artery pseudoaneurysm. Typical causes include pancreatitis and trauma. Rarely, the rupture of a pseudoaneurysm presents as upper gastrointestinal (UGI) bleeding. Among causes, peptic ulcer is the casuistic one.

Case report: This report describes a very rare case of recurrent UGI bleeding from a splenic artery pseudoaneurysm caused by a penetrating gastric ulcer. After negative results of endoscopy and ultrasound, the diagnosis was established in CT angiography. The successful treatment consisted of surgical ligation of the bleeding vessel and suture of the ulcer with preservation of the spleen and pancreas, which is rarely tried in such situations.

Conclusions: The most important factor in identifying a ruptured splenic artery pseudoaneurysm as a source of GI bleeding is considering the diagnosis. UGI hemorrhage from splenic artery pseudoaneurysm can have a relapsing course providing false negative results of endoscopy and ultrasound if performed between episodes of active bleeding. In such cases, immediate CT angiography is useful in establishing diagnosis and in application of proper therapy before possible recurrence.

No MeSH data available.


Related in: MedlinePlus