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GASTRO-INTESTINAL RADIOLOGY Table of Contents   
Year : 1999  |  Volume : 9  |  Issue : 1  |  Page : 13-15
Case report : Duplex imaging of a tuberculous etiology common hepatic artery aneurysm causing hematemesis


1 Department of Radiodiagnosis, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Pondicherry-605006, India
2 Department of Pathology, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Pondicherry-605006, India

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Keywords: Common hepatic artery, Aneurysm, Tuberculosis, Ultrasound

How to cite this article:
Deol PS, Gopinath R G, Elangovan S, Anil K. Case report : Duplex imaging of a tuberculous etiology common hepatic artery aneurysm causing hematemesis. Indian J Radiol Imaging 1999;9:13-5

How to cite this URL:
Deol PS, Gopinath R G, Elangovan S, Anil K. Case report : Duplex imaging of a tuberculous etiology common hepatic artery aneurysm causing hematemesis. Indian J Radiol Imaging [serial online] 1999 [cited 2019 Aug 19];9:13-5. Available from: http://www.ijri.org/text.asp?1999/9/1/13/28363
Hepatic artery aneurysms - the second most common aneurysm of splanchnic vessels - are asymptomatic, but they may progress and cause specific symptoms such as abdominal discomfort and pain [1]. Spontaneous rupture is an uncommon but disastrous complication associated with a very high mortality rate [2]. Ultrasound provides a non-invasive method for detecting such lesions. This case report describes a tuberculous common hepatic artery aneurysm diagnosed by real time duplex sonograph.


   Case Report Top


A fourteen-years-old boy who had a one-month history of increasing lethargy and intermittent abdominal pain presented to the hospital with hematemesis. On physical examination, there were multiple neck nodes. No organomegaly was detected. Blood pressure, pulse rate and routine laboratory tests were normal with the exception of an elevated ESR of 75 mm/h. His chest radiograph revealed multiple discrete nodules. A provisional clinical diagnosis of disseminated tuberculosis was made.

A real time US of the abdomen revealed two hypoechoic masses in the pancreatico-duodenal area. The hypoechoic masses had a small communicating channel. Because of their localization and configuration (hypoechoic center surrounded by a homogeneous echogenecity), a Doppler examination was performed [Figure - 1], which showed a typical arterial waveform within the hypoechoic masses. The gall bladder was not separately visualized. Pericardial effusion was detected. Before CT/angiography could be performed, the boy experienced another episode of massive hematemesis and could not be revived. Autopsy revealed a cystic mass arising from the common hepatic artery with rupture into the gall bladder [Figure - 2].

A final diagnosis of common hepatic artery aneurysm with spontaneous rupture into the gall bladder was made. The etiology was tuberculosis as confirmed by histopathology.


   Discussion Top


Hepatic artery aneurysms are the second most common splanchnic aneurysms after those of the splenic artery [3]. Atherosclerosis, infection (often mycotic) and trauma account for most of these aneurysms. Hereditary telangiectasia, cystic medial necrosis, pancreatitis, vasculitis, liver abscess and tuberculosis are less common causes [3],[4],[5],[6]. Among patients with hepatic aneurysm who are symptomatic, the majority present with episodes of epigastric or right upper quadrant pain followed in frequency by gastrointestinal hemorrhage and jaundice [3],[6].

The classic triad of abdominal pain, hemobilia and obstructive jaundice is observed in only 30% of patients. When these findings accompany an abdominal bruit or a pulsatile mass, the diagnosis of a hepatic artery aneurysm should be suspected. The aneurysm may rupture into the peritoneal cavity, extra-hepatic bile duct, duodenum, portal vein, and stomach and rarely into the gall bladder [4]. Extra-hepatic aneurysms are four times more common than intra-hepatic aneurysms. They have a high incidence of rupture and an associated mortality of 82 percent [7].

A literature search on tuberculosis as an etiology for common hepatic artery aneurysm could not reveal any English language reference in recent years, upto 1966. A German language by Klepetko describes tuberculous aneurysms of hepatic artery as a rare cause of hemobilia [8].

The sonographic diagnosis of the aneurysm was possible since the hypoechoic mass was related to the common hepatic artery and revealed an arterial wave pattern on Doppler examination.

 
   References Top

1.Stanley JC. Splanchnic artery aneurysms. In: Rutherford RB ed. Vascular surgery. Philadelphia: W.B. Saunders, 1977: 673-685.   Back to cited text no. 1    
2.Harris RD, Anderson JE, Coel MN. Aneurysm of the small pancreatic arteries, a cause of upper abdominal pain and intestinal bleeding. Radiology 1975; 115:17-20.   Back to cited text no. 2  [PUBMED]  
3.Drum DE. Current status of radio-colloid hepatic scintigraphy for space occupying disease. Semin Nucl Med 1982; 13: 62-74.   Back to cited text no. 3    
4.Freedman AC, Johns T, Levy DW. Cirrhosis, other diffuse disease, portal hypertension and vascular disease. In: Freidman AC ed. Radiology of the liver, Biliary Tract, Pancreas and Spleen. Baltimore, Williams and Wilkins, 1987: 66-149.   Back to cited text no. 4    
5.Baert AL, Fevery J, Marchal G. Early diagnosis of Budd Chiari syndrome by computed tomography and ultrasonography report of five cases. Gastroenterology 1983; 84: 587-595.   Back to cited text no. 5    
6.Salo JA, Aarino PT, Jarvinen AA. Aneurysm of the hepatic arteries. Am J Surg 1989; 55: 705-709.   Back to cited text no. 6    
7.Richard M Gore. Vascular disorders of the liver and splanchnic circulation. In: Gore RM, Levine MS, Laufer I, eds. Textbook of gastrointestinal Radiology - volume 2. Philadelphia: WB Saunders, 1994: 2018-2050.   Back to cited text no. 7    
8.Kleptko W, Laufer G. Grabenwoger F, Schwarz C, Kreuzer W. Tuberculous aneurysms of the hepatic artery - a rare cause of hemobilia. Chirurg 1986; 57: 522-524  Back to cited text no. 8    

Top
Correspondence Address:
Parminder S Deol
Department of Radiodiagnosis, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Pondicherry-605006
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2]

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