Gastroduodenal artery pseudoaneurysm: A rare complication of pancreatitis

Asish Pavanan; Shirish V Vaidya; KB Harshith Gowda; Rajasbala Pradeep Dhande

doi:10.4103/jdmimsu.jdmimsu_79_22

CASE REPORT

Year : 2022 | Volume : 17 | Issue : 4 | Page : 957-959

Gastroduodenal artery pseudoaneurysm: A rare complication of pancreatitis

Asish Pavanan, Shirish V Vaidya, KB Harshith Gowda, Rajasbala Pradeep Dhande
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Submission	26-Feb-2022
Date of Decision	27-Sep-2022
Date of Acceptance	07-Dec-2022
Date of Web Publication	10-Feb-2023

Correspondence Address:
Dr. Asish Pavanan
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Wardha - 442 001, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_79_22

Abstract

Gastroduodenal artery pseudoaneurysms are rare complications of pancreatitis and commonly manifest as abdominal pain and gut bleeding due to rupture. Usually, these vascular complications are asymptomatic and are thus diagnosed incidentally on magnetic resonance imaging or computed tomography examination. Pseudoaneurysms should be treated immediately after diagnosis because of the higher rate of mortality (90%) in untreated cases, whereas 12% in treated cases. Herein, we describe a unique case of gastroduodenal artery pseudoaneurysm in a 29-year-old male patient with chronic pancreatitis, which was treated successfully with embolization.

Keywords: Embolization, hepatic artery, magnetic resonance imaging, main pancreatic duct, visceral artery

How to cite this article:
Pavanan A, Vaidya SV, Harshith Gowda K B, Dhande RP. Gastroduodenal artery pseudoaneurysm: A rare complication of pancreatitis. J Datta Meghe Inst Med Sci Univ 2022;17:957-9

How to cite this URL:
Pavanan A, Vaidya SV, Harshith Gowda K B, Dhande RP. Gastroduodenal artery pseudoaneurysm: A rare complication of pancreatitis. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Apr 1];17:957-9. Available from: http://www.journaldmims.com/text.asp?2022/17/4/957/369518

Introduction

Pseudoaneurysms and visceral artery aneurysms are uncommon complications of pancreatitis with potential morbidity and mortality, hemorrhage being the most life-threatening complication.^[1] Usually, these vascular complications are asymptomatic and are thus diagnosed incidentally on magnetic resonance imaging (MRI) or computed tomography (CT) examination.^[2] However, angiography is essential for prompt diagnosis and management. Involvement of the splenic artery is more common in around 50% of patients, followed by the pancreaticoduodenal, gastroduodenal, superior mesenteric, hepatic artery, and left gastric.^[3] Early diagnosis and prompt treatment are essential because of their instability accompanied by a significant risk of massive bleeding.^[2] Current treatment options are endovascular embolization and surgery in cases of intra-abdominal hemorrhage. Management usually depends on the vascular location; embolization is usually considered for pseudoaneurysms in solid organs, whereas the sandwich technique is in case of collateral flow.^[2],[3]

Case Report

A 29-year-old male, a known case of chronic pancreatitis presented to the casualty department with chief complaints of 5 days of acute onset of left hemiplegia with seizures, abdominal pain from 1.5 years, multiple episodes of vomiting, and loss of appetite. With chronic pancreatitis presenting with hematemesis and abdominal pain is very rare. The patient had admitted in the isolation ward for COVID-19 investigation and reports were found to be negative. The patient had a history of vomiting and seizures without loss of consciousness. On admission, vitals were blood pressure of 120/90 mm of Hg, pulse rate of 78 bpm, and respiratory rate of 20 cpm. On systemic examination, all systems were found to be normal. Laboratory investigations revealed a hemoglobin of 8.2%, hematocrit of 25.1%, white blood cell count of 8200, an international normalized ratio of 1.56, urea of 16, creatinine of 0.4, sodium of 134, potassium of 3.7, alkaline phosphatase of 99, aspartate transaminase of 52, albumin of 3, globulin of 3.7, lipase of 937, total bilirubin of 1.0 (conjugated bilirubin of 0.3+ unconjugated bilirubin of 0.7), and serum ionic calcium of 4. MRI of the brain revealed a hemorrhagic transformation of the infarct in right perirolandic region. CT of the abdomen and pelvis revealed chronic calcific pancreatitis with mild ascites. The pancreas was atrophic with mildly dilated main pancreatic duct, heterogenous enhancement, and e/o multiple areas of coarse calcifications [Figure 1]. There was e/o large heterogeneous mixed-density lesion near the region of the head of the pancreas with peripheral calcifications, measuring 9 cm × 6.5 cm in size; the lesion was nonenhancing and showed multiple concentric hypodense and hyperdense layers within causing mass effect on common bile duct leading to intrahepatic biliary radicals' dilatation. Superiorly, the lesion was abutting the common hepatic artery and causing splaying of the gastroduodenal artery medially from its origin resulting in the widening of the C loop of the duodenum [Figure 2]. Based on the subjective and objective evaluation, the patient was diagnosed with acute infarct in the brain with gastroduodenal artery pseudoaneurysm and duodenal ulcer. The patient was shifted to neuro ward where the patient was managed with antibiotics, analgesics, antacids, antiepileptic, and other supportive measures. Later, the patient was shifted to the neuro intensive care unit (ICU) due to a sudden fall in blood pressure and oxygen saturation. Intervention radiology opinion was considered, and angioembolization of gastroduodenal artery pseudoaneurysm was done.

Figure 1: CT of abdomen and pelvis; atrophic pancreas with mild dilated MPD (white arrow block), heterogenous enhancement and e/o multiple areas of coarse calcifications. CT: Computed tomography, MPD: Main pancreatic duct

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Figure 2: Large heterogeneous mixed-density lesion near the region of the head of the pancreas with peripheral calcifications, measuring 9 cm × 6.5 cm in size

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Patient's perspective

I was a patient of chronic pancreatitis. I had complaints of acute onset of abdominal pain, vomiting and seizures without loss of consciousness, and loss of appetite before I visited OPD. I was hospitalized and evaluated for a routine checkup. Based on the radiological evaluation, I was diagnosed with gastroduodenal artery pseudoaneurysm and duodenal ulcer. Clinicians processed for angioembolization of gastroduodenal artery pseudoaneurysm. I was in ICU for 4 days for close monitoring. Once the hemodynamic condition was stabilized, I was discharged.

Discussion

Pelvic and abdominal visceral artery aneurysms include true or false aneurysms (pseudoaneurysms); true aneurysms have all three layers of the artery, and pseudoaneurysms lack a complete vessel wall and are derived from one or more injured arterial wall layers. Most true aneurysms result from the digestion of the arterial tunica media in the setting of fibromuscular dysplasia, atherosclerosis, or collagen vascular disorders. True aneurysms can lead to in situ thrombosis (with or without distal embolization), compression of adjacent structures, and hemorrhagic rupture being a life-threatening complication.^[2],[4] Most pelvic and abdominal pseudoaneurysms can lead to compression of adjacent structures, early rupture, and a higher chance of infection of the aneurysm. Pancreatic pseudoaneurysm is an uncommon complication of pancreatitis, created from the erosion of the pancreatic artery into a pseudocyst. However, it may occur after gastric or pancreatic bypass surgery or trauma.^[3] The cause of gastroduodenal artery pseudoaneurysm in our patient is chronic pancreatitis. Among different case series, the incidence of pancreatic pseudoaneurysms ranges from 1.3% to 10%.^[5] With the evolution of advanced imaging modalities including MRI, CT, arteriography, and ultrasound, the incidental detection rate of asymptomatic pseudoaneurysms has been increased in recent times. In addition, advanced endovascular and endoscopic techniques with the instrumentation of splanchnic and biliary tract vasculature have also raised the detection rate of iatrogenic pseudoaneurysms.^[6]

Gastroduodenal pseudoaneurysm commonly manifests as abdominal pain (46%) or gut bleeding due to rupture (52%); mostly asymptomatic (7.5%) and rarely as intraperitoneal bleed, retroperitoneal bleed, or bleeding into the common bile duct or pancreatic duct.^[7] In patients complaining with abdominal pain only as in the current case report, it would be difficult to distinguish pseudoaneurysm from pancreatitis (especially in a chronic state), they usually have similar manifestations. CT of the pelvis and abdomen with contrast (sensitivity of 67%) is often suggestive, however, CT angiogram is the most reliable and standard imaging modality for the diagnosis with a sensitivity of 100%.^[8] Pseudoaneurysm should be treated immediately after diagnosis because of a higher rate of mortality (90%) in untreated cases, whereas 12% in treated cases.

Treatment options include either surgery or embolization (covered stent, coils, transcatheter, or percutaneous thrombin injection). A high percentage of the research has reported that endovascular therapy has demonstrated a potential benefit in terms of shorter hospital stay, less postoperative pain, and early recovery. Resection of the pancreas with a false aneurysm or direct ligation of the bleeding artery should be performed in case of rebleeding postsurgery or failed embolization.^[9],[10] However, embolization is considered the treatment of choice in diffused bleeding conditions or unstable patients. Patients should be monitored very closely after embolization for complications, such as rebleeding (early or late), which can observe in 20%–40% of patients.^[4] Despite embolization being the highly successful and recommended treatment procedure, still there is a greater risk of recurrence with a mortality rate of 16%; the mortality rate varies from 20% to 30% after surgery.^[2] A 10-year retrospective case series (1999–2009) on pseudoaneurysms (118 cases) and visceral artery aneurysms (67 cases) reported that all cases were successfully managed with endovascular techniques, emphasizing the effectiveness of minimally invasive procedures.^[11]

Take away points

Gastroduodenal artery pseudoaneurysm rupture is a rare, life-threatening condition, causing rapid fatality due to gastrointestinal (GI) tract bleeding
This article helps to highlight the importance of recognizing and managing a pseudoaneurysm rupture in patients presenting with symptoms of a massive GI bleed and a history of recent pancreatitis, vascular, or laparoscopic intervention. Furthermore, we propose that GDA pseudoaneurysms should be considered in patients with recurrent UGI bleeding.

Conclusion

Gastroduodenal artery pseudoaneurysms are uncommon and asymptomatic. Hence, it should be given importance in the differential diagnosis in chronic pancreatitis patients presenting with abdominal pain. Early diagnosis and treatment are essential because of the increased rate of life-threatening complications and mortality if left untreated.

Consent

Both verbal and informed written consent were obtained from the patient and his relatives.

Declaration of patient consent

We have obtained all appropriate written informed consent from the patient and his relatives. In the form, the patient has given his consent for images and other clinical information reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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