Case An uncommon cause of digestive bleeding: diagnostic approach and interventional treatment

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1 Case An uncommon cause of digestive bleeding: diagnostic approach and interventional treatment Matteoli Marco, Tesei Jacopo, Rossi Michele, David Vincenzo Sant'Andrea Hospital Section: Abdominal Imaging Published: 2013, Jan. 12 Patient: 45 year(s), male Authors' Institution Sant'Andrea Hospital, II Faculty of medicine "La Sapienza, Radiology; via di grottarossa 1035 Roma, Italy; Clinical History 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. Imaging Findings 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

2 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). Discussion 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 % 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. Final Diagnosis Pancreatic pseudocyst, fistuled with a pseudoaneurysm of a ramus of left gastric artery. Differential Diagnosis List Pseudoaneurysm, Gastric cancer, Pancreatic cancer Figures Figure 1 Digestive endoscopy findings

3 A neo formation jutting out the lumen, and covered with hyperplastic mammillated mucosal, with a bleeding focal corrosion in the central region. Procedure: Endoscopy; Figure 2 16RowMDCT evaluation in arterial and venous phase Department of Gatroenterology, San Filippo Neri, Rome A pseudo-nodular injury at the tail of the pancreas, after administration of intravenous contrast medium a slow filling in the lesion was seen, arterial phase shows the normal caliper of peripancreatic vessels.

4 Imaging Technique: CT-Angiography; Procedure: Catheters; A pseudo-nodular injury at the tail of the pancreas, after administration of intravenous contrast medium filling of the active lesion was seen, most evident in the venous phase. Slight inhomogeneity of adipose tissue in the pancreatic tail, an irregular appearance of the duct of Wirsung, (black arrow), and intrapancreatic calcification (white arrow), was the CT diagnostic criteria for chronic pancreatitis.

5 Procedure: elearning; Special Focus: Inflammation; Figure 3 Angiogram of left gastric artery The angiogram of the left gastric artery showed a contrast blush suggestive of active bleeding. Imaging Technique: Fluoroscopy; Department of Radiology, Sant'Andrea Hospital, II Faculty of medicine "La Sapienza, Roma, Italy;

6 The angiogram of the left gastric artery showed a contrast blush suggestive of active bleeding. Imaging Technique: Fluoroscopy; Department of Radiology, Sant'Andrea Hospital, II Faculty of medicine "La Sapienza, Roma, Italy; A super-selective angiogram of the left gastric artery at the emerging of the pseudo-aneurysm failed, due to arterial spasm, so the embolisation strategy was to close the artery proximately with spongostan. Imaging Technique: Fluoroscopy; Department of Radiology, Sant'Andrea Hospital, II Faculty of medicine "La Sapienza, Roma, Italy;

7 Figure 4 Embolization evaluated with CT examination The CT performed after the embolisation showed no evidence of arterial hyperdensity within the collection situated among the little curve of the stomach a the pancreatic tail. The CT performed after the embolisation showed no evidence of venous hyperdensity within the collection situated among the little curve of the stomach a the pancreatic tail.

8 MeSH Pancreas [A03.734] A mixed exocrine and endocrine gland situated transversely across the posterior abdominal wall in the epigastric and hypochondriac regions. The endocrine portion is comprised of the ISLETS OF LANGERHANS, while the exocrine portion is a compound acinar gland that secretes digestive enzymes. Pancreatic Insufficiency [C ] Absence of or reduced pancreatic exocrine secretion into the duodenum and resultant poor digestion of lipids, vitamins, nitrogen, and carbohydrates. Catheterization [E02.148] Use or insertion of a tubular device into a duct, blood vessel, hollow organ, or body cavity for injecting or withdrawing fluids for diagnostic or therapeutic purposes. It differs from INTUBATION in that the tube here is used to restore or maintain patency in obstructions. References [1] Maus TP (1993) Pseudoaneurysm haemorrhage as a complication of pancreatitis Mayo Clin Proc 68:895-6 [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 [3] Burke JW, Erickson SJ, Kellum CD, Tegtmeyer CJ, Williamson BRJ, Hansen MF. (1986) Pseudoaneurysms complicating chronic pancreatitis: detection with CT Radiology 161: [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: [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 [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): [7] Byrne MF, Mitchell RM, Baillie J. (2002) Pancreatic Pseudocysts. Curr Treat Options Gastroenterol. Oct;5(5): [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):

9 [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): Citation Matteoli Marco, Tesei Jacopo, Rossi Michele, David Vincenzo (2013, Jan. 12) An uncommon cause of digestive bleeding: diagnostic approach and interventional treatment {Online} URL: