All That Bleeds! Visceral Artery Pseudo Aneurysm as a Rare Cause of Recurrent Fresh Gastrointestinal Bleeding 1954

• Published in: The American journal of gastroenterology Vol. 113; no. Supplement; pp. S1113 - S1114
• Main Authors: Bajwa, Maria, Genese, Thomas, Cloud, Adam
• Format: Journal Article
• Language: English
• Published: New York Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins 01.10.2018
• Subjects: Abdomen; Alcohol abuse; Aneurysms; Colonoscopy; Cysts; Endoscopy; Gastroenterology; Hematemesis; Hypertension; Pancreatitis; Veins & arteries
• ISSN: 0002-9270; 1572-0241
• DOI: 10.14309/00000434-201810001-01954

Visceral artery aneurysm and pseudoaneurysm are rare with incidence of 0.1-2%.We report a case of pancreato-duodenal artery pseudoaneurysm presenting as recurrent upper and lower GIB. CASE PRESENTATION: A 57 year old male with past history of COPD, hypertension, GERD, chronic hepatitis C,and alcohol abuse, presented with diffuse abdominal pain.His symptoms started nearly two weeks prior with hematemesis and lower GIB. An upper endoscopy and colonoscopy failed to identify source of bleeding.Two days later he had another episode of fresh upper and lower GI bleeding.Repeat endoscopy revealed no source.On third occassion patient reported diffuse abdominal pain, followed by mild nausea,vomiting and large amount of fresh blood hematemesis and bleeding per rectum. Abdominal CT angiogram revealed acute on chronic pancreatitis, atrophy of pancreatic body and multiple pseudocysts.A 4.6x3.2 cm pseudoaneurysm anterior to splenic artery anatomically was located in close proximity to posterior gastric wall with possible erosion. During endovascular repair a small branch of gastro-duodenal artery was identified as vessel of origin. Multiple micro-catheter coils were used to fill and obliterate the sac and feeding vessel. At six month follow up pseudoaneursym was stable on imaging. DISCUSSION ETIOLOGY: True aneurysms are caused by hypertension, atherosclerosis,and connective tissue disease.Two-thirds of VAPA are secondary to pancreatitis and leaking of proteolytic enzymes.PRESENTATION:Most cases present with vague abdominal symptoms.If ruptured, patients present with anemia and hemodynamic instability. DIAGNOSIS: Color Doppler can display inflow and outflow of blood in sac, known as "yin-yang sign'.Transcatheter angiography remains gold-standard for diagnosis as it can provide definitive diagnosis, has highest sensitivity (100%) and therapeutic potential. TREATMENT: Treatment is indicated if a visceral aneurysm size is >2cm. Women of child bearing age or pregnant should also undergo treatment.A pseudoaneurysm must be treated immediately as rate of expansion is much rapid(76.3% vs 3.1%). Treatment options include endovascular(stent,em bolization),percutaneous thrombin injection,and surgery(vessel ligation,arterial bypass,sac exclusion). CONCLUSION:This case reports highlights importance of including VAA and VAPA in differential diagnosis of GI bleeding and use of alternative diagnostic modalities when endoscopy and colonoscopy fail to reveal a source of bleeding.