Embolisation of gastroduodenal artery aneurysm caused by chronic pancreatitis.

Abstract

SUMMARY Chronic pancreatitis is known to cause vascular lesions, which produce gastrointestinal haemorrhage. Visceral vessel aneurysms are an unexpectedly common finding in arteriograms of patients with chronic pancreatitis. Gastrointestinal bleeding from these aneurysms carries a high mortality, making early diagnosis and treatment essential. Coeliac and mesenteric arteriography readily confirm the diagnosis. Surgical ligation or resection of the aneurysm entails a high mortality. Cessation of such gastrointestinal haemorrhage may be achieved by transcatheter embolisation under radiological control. This report describes a case in which bleeding from a gastroduodenal artery aneurysm, caused by chronic pancreatitis, was successfully treated by embolisation using a Gianturco coil.Gastrointestinal haemorrhage is a recognised complication of chronic pancreatitis and has been reported to occur in up to 9% of cases.' Several aetiological factors such as local venous hypertension secondary to splenoportal thrombosis, erosion of vessels in the walls of neighbouring viscera, formation of visceral vessel aneurysms and bleeding from a pseudocyst into the pancreatic duct, have been described to account for the gastrointestinal haemorrhage.' The incidence of visceral vessel aneurysms, detected by coeliac arteriography, in cases of chronic pancreatitis has been reported to be as high as 10%.2 Erosion and weakening of the arterial wall, responsible for aneurysm formation, is primarily because of the enzymatic actions of elastase and trypsin, which are released in large amounts in pancreatitis.3 The majority of such aneurysms occur on the splenic artery and a few occur on the common hepatic, gastroduodenal and pancreatic-duodenal arteries. Half of these aneurysms rupture and cause gastrointestinal bleeding,4 which has -a high mortality. Often surgical ligation or resection of the bleeding aneurysm is hazardous or not possible.7 Selective embolisation of the aneurysm by delivering an occluding agent

Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

“…As an alternative modality for the management of arterial bleeding, embolization, where the bleeding artery is clotted by platinum spirals or gelatin sponges, is the primary nonsurgical, radiological interventional treatment option . In our patient, in spite of superselective angiography, an artery causing the hemorrhage was not identified.…”

“…These pseudoaneurysms result from weakening of the arterial wall caused by partial enzymatic digestion and pressure necrosis by the pseudocyst 3. The incidence of pseudoaneurysmal hemorrhage in patients with pseudocyst is 10% 4. Chronic exposure of the arterial wall to digestive enzymes, and traction resulting from scarring and granulation in the wall of the pseudocyst may be important factors in initiating gastrointestinal hemorrhage.…”

Haemorrhage following Pancreaticoduodenectomy: Risk Factors and the Importance of Sentinel Bleed

“…The main cause of bleeding in this situation is the rupture of arterial pseudoaneurysms in the operating field. Different pathophysiological mechanisms have been suggested for this entity which mainly causes delayed massive haemorrhage [13,24,25,26,27,28,29,30,31]. …”

Pseudoaneurysm of the Dorsal Pancreatic Artery with Obstruction of the Celiac Axis After Pancreatoduodenectomy: Report of a Case

“…Moreover, a postoperative intra-abdominal hematoma that fails to resorb may serve as a nidus for infection near a peripancreatic vessel, and form a pseudoaneurysm. 10 Preoperative radiation therapy is also a risk factor for pseudoaneurysm formation. Reber et al 3 reported three cases of ruptured extrahepatic pseudoaneurysm without clinical evidence of leakage from the pancreatojejunostomy, and speculated that minor injuries caused during the dissection led to pseudoaneurysm formation.…”