Rupture of hepatic artery aneurysm associated with ischemic hepatitis

Abstract

Hepatic artery aneurysms are scarcely reported, mainly because of non-specific symptoms. More often, they are incidental findings during imaging studies to investigate other acute or chronic abdominal conditions. These aneurysms are usually detected in the sixth decade of life, predominantly among males.We report the case of a 69 year-old female with an unsuspected huge hepatic artery aneurysm associated with ischemic hepatitis. Suspicion of aneurysm arose during imaging studies to clarify the origin of jaundice and abdominal pain. After establishment of the diagnosis, but before open surgery, there was a spontaneous rupture of the aneurysm, which caused hemoperitoneum and death. The necropsy study confirmed ischemic hepatitis.Hepatic artery aneurysms are second among the visceral aneurysms, and may cause abdominal pain, jaundice, and hemorrhagic events.One should suspect abdominal aneurysms in elderly patients with unclear abdominal pain, and this hypothesis should be ruled out by imaging studies.Key words. Aneurysmal rupture. Hepatic artery. Hemoperitoneum. Ischemic hepatitis REsUMEnLa publicación de trabajos sobre aneurismas en la arteria hepática es escasa, debido a los síntomas no específicos y a que constituyen hallazgos incidentales durante investigación de otras condiciones abdominales agudas o crónicas. Estos aneurismas son más frecuentes en varones y en la sexta década de la vida.Presentamos el caso de una mujer de 69 años de edad que ingresa en el hospital con un aneurisma de arteria hepática no sospechado previamente, asociado con hepatitis isquémica. La sospecha de aneurisma empezó durante estudio de imágenes para aclaramiento del origen de ictericia y dolor abdominal. Después de confirmado el diagnóstico, pero antes de la operación planeada, ocurrió rotura espontánea del aneurisma causando hemoperitoneo y muerte. El estudio de necropsia confirmó hepatitis isquémica.Los aneurismas de la arteria hepática son los segundos entre los aneurismas viscerales y pueden causar dolor abdominal, ictericia y eventos hemorrágicos. Debemos sospechar de aneurisma visceral en ancianos con dolor abdominal no aclarada, posibilidad que debe ser descartada por estudios de imágenes.

Ischemic hepatitis: A severe concern

“…The authors described the current concept, pathophysiology, clinical and anatomopathological features, diagnostic tools, and prevention and management of this ominous condition [1] . Ischemic hepatitis affects men at mean age of 64-70 years; the mortality rate is >50% [1][2][3] .…”

“…The general incidence is 2 per 1000 patients, but in ICUs it may be up to 2.5 per 100 [1] . Diagnostic criteria include: cardiac, circulatory, or respiratory failure; dramatic transient rise of aminotransferase levels; and exclusion of other causes of liver cell necrosis [1][2][3] . The aminotransferase and lactate dehydrogenase levels typically peak within 24 hours, drop to nearly half values in 24 to 72 hours, and normalize between 1 to 2 weeks [1][2][3] .…”

“…Diagnostic criteria include: cardiac, circulatory, or respiratory failure; dramatic transient rise of aminotransferase levels; and exclusion of other causes of liver cell necrosis [1][2][3] . The aminotransferase and lactate dehydrogenase levels typically peak within 24 hours, drop to nearly half values in 24 to 72 hours, and normalize between 1 to 2 weeks [1][2][3] . Liver biopsy can confirm the diagnosis in doubtful cases by demonstrating centrilobular necrosis [1][2][3] ; however this procedure may be hazardous in presence of coagulopathy.…”

“…The aminotransferase and lactate dehydrogenase levels typically peak within 24 hours, drop to nearly half values in 24 to 72 hours, and normalize between 1 to 2 weeks [1][2][3] . Liver biopsy can confirm the diagnosis in doubtful cases by demonstrating centrilobular necrosis [1][2][3] ; however this procedure may be hazardous in presence of coagulopathy. Therapy directed to liver is unavailable, and one must correct predisposing factors [1][2][3] .…”

Rotura de aneurisma de arteria hepática como causa infrecuente de dolor abdominal y hemorragia digestiva

“…hemorragia digestiva alta, al alcance del gastroscopio, y que no es causado directamente en el intestino delgado. Por tanto, se considera una causa de sangrado digestivo de origen oscuro(1,2).La clínica de la hemobilia se caracteriza por la aparición de ictericia, dolor en el hipocondrio derecho y hemorragia digestiva alta(3)(4)(5), síntomas que se presentaron en nuestro paciente. Las causas descritas son traumáticas, iatrogénicas, inflamatorias, infecciosas, neoplásicas y vasculares, tales como los aneurismas, las vasculitis y las malformaciones arteriovenosas.En consecuencia, el diagnóstico se realiza mediante una prueba de imagen (6, 7), ya sea una TC, una EDA o una resonancia magnética nuclear (RMN)(8).…”