An unusual source of right upper quadrant pain

Transcription

1 Originally Posted: Month, 00, 20xx An unusual source of right upper quadrant pain Resident(s): Ashish R. Vyas MD (PGY-V), Dominic T. Semaan M.D., J.D. (PGY-V) Attending(s): Dr. Denis Lincoln Program/Dept(s): Providence Hospital and Medical Center, Department of Radiology, Southfield, Michigan

2 Chief Complaint & HPI Chief Complaint and/or reason for consultation 78-year-old male with right upper quadrant abdominal pain for the last 2-3 weeks. History of Present Illness Migrating upper abdominal pain for 2-3 weeks, primarily in RUQ, of 8/10 severity Associated with nonbilious vomiting, particularly after meals Decreased appetite for last few weeks

3 Relevant History Past Medical History Coronary artery disease and benign prostatic hyperplasia Past Surgical History: Cardiac catheterization with stent placement Family & Social History: Married, smokes 1-2 g of marijuana/day. Long history of tobacco use quit 15 years ago Review of Systems: As per HPI Medications: Plavix, Coreg, Flomax, Motrin Allergies: Penicillin

4 Diagnostic Workup Physical Exam Vital signs stable on exam Abdomen: Soft with active bowel sounds. A pulsatile, tender and firm mass is palpable in the RUQ measuring approximately 4 x 5 cm just below right costal margin, midclavicular line and associated with tenderness to palpation Laboratory Data Creatinine: 1.5 mg/dl Hb: 8.4 gm/dl

5 Diagnostic Workup CT Abdomen & Pelvis Large pseudoaneurysm in the right upper quadrant. Fluid-filled and distended stomach with gastric outlet obstruction to the level of the junction of D1/D2

6 Diagnostic Workup CT angiography Coronal CTA shows the large, partially thrombosed pseudoaneurysm Bilateral common iliac artery aneurysms. Bilateral internal iliac artery aneurysms were also present (not shown). Infrarenal AAA

7 Diagnosis 7 x 4 cm partially thrombosed pseudoaneurysm of a branch of the right colic artery resulting in an element of gastric outlet obstruction Additional findings of: Fusiform, 4 cm infrarenal AAA Bilateral common iliac artery aneurysms measuring up to 3 cm Bilateral internal iliac artery aneurysms up to 3 cm Beaded, tortuous celiac axis

8 Intervention The patient was seen by general and vascular surgery regarding abdominal pain and the large pseudoaneurysm Patient was poor surgical candidate and would likely require large colonic resection with possibility of excessive blood loss Vascular surgery was uncomfortable with mesenteric endovascular options and subsequently consulted IR IR accepted case and planned to coil embolize the pseudoaneurysm with general and vascular surgical standby in case of resulting colonic ischemia

9 Intervention Mesenteric angiography with embolization SMA catheterization with RC1 catheter and contrast injection reveals a beaded, tortuous SMA and early and delayed filling of the pseudoaneurysm. A replaced right hepatic artery is noted. The infrarenal AAA is partially visualized.

10 Intervention Mesenteric angiography with embolization Utilizing a Progreat microcatheter, the feeding vessel was superselectively catheterized and coil embolized with a combo of 25 mm x 60cm, 22mm x 50 cm, 20 mm x 50 cm and 13 mm x 40 cm coils units of thrombin was also injected into the pseudoaneurysm apex. Completion angiography revealed near stagnation of flow within the pseudoaneurysm.

11 Clinical Follow Up Patient was reevaluated with ultrasound in 24 hours to confirm pseudoaneurysm thrombosis

12 Follow-up Ultrasound ABOVE: Color Doppler reveals patent pseudoaneurysm RIGHT: After US-guided injection with 2000 Units thrombin, the pseudoaneurysm has no further flow

13 Clinical Follow Up Patient had no further abdominal pain after embolization and thrombin injection Outpatient follow-up with Rheumatology to evaluate for possible connective tissue disease or vasculitis IR follow-up in one month in clinic

14 Question Slide Pseudoaneurysm occurrence in the mesenteric vessels is most commonly seen in what setting? A: Trauma B: Iatrogenic C: Pancreatitis D: Vasculitis

15 Correct Pseudoaneurysm occurrence in the mesenteric vessels is most commonly seen in what setting? A: Trauma B: Iatrogenic C: Pancreatitis D: Vasculitis Return to case

16 Sorry, That s Incorrect Pseudoaneurysm occurrence in the mesenteric vessels is most commonly seen in what setting? A: Trauma B: Iatrogenic C: Pancreatitis D: Vasculitis Return to case

17 Summary & Teaching Points Mesenteric pseudoaneurysms in the absence of pancreatitis, trauma or surgery, are a very rare entity IR plays a key role in the management and treatment of pseudoaneurysms Coil embolization, thrombin administration, and covered stent placement are mainstays in endovascular treatment of pseudoaneurysms Close clinical and imaging follow-up is necessary to monitor for complete thrombosis, possible hemorrhage from rupture, and bowel ischemia

18 References & Further Reading Kim SK, Lee J, Duncan JR, Picus DD, Darcy MD, Sauk S. Endovascular treatment of superior mesenteric artery pseudoaneurysms using covered stents in six patients. AJR Am J Roentgenol Aug;203(2): Nagar N, Dubale N, Jagadeesh R, Nag P, Reddy N, Rao GV. Unusual locations of pseudoaneurysms as a sequel of chronic pancreatitis. J Interv Gastroenterol Jan-Mar; 1(1): Takasugi S, Kaminou T, Ohuchi Y, YataS, Adachi A, Kawai T, Endo M, Ogawa T. Coil embolization with side-holed catheter to preserve peripheral flow for visceral artery pseudoaneurysm: an experimental study in Swine. J Vasc Interv Radiol Dec;25(12):