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Year : 1999  |  Volume : 9  |  Issue : 2  |  Page : 90-91
Hepatic artery pseudoaneurysm complicating pancreatitis


Department of Radiodiagnosis, Kasturba Medical College, Manipal, Karnataka, India

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How to cite this article:
Banavali SM, Lakhkar BN. Hepatic artery pseudoaneurysm complicating pancreatitis. Indian J Radiol Imaging 1999;9:90-1

How to cite this URL:
Banavali SM, Lakhkar BN. Hepatic artery pseudoaneurysm complicating pancreatitis. Indian J Radiol Imaging [serial online] 1999 [cited 2019 Jul 15];9:90-1. Available from: http://www.ijri.org/text.asp?1999/9/2/90/28346
Sir,

US and CT manifestations of pancreatitis have received much attention in literature. The detection of complications such as pseudocysts and abscesses has been discussed extensively. Relatively little mention has been made of the role of imaging modalities in the detection of associated vascular complications, in particular, pseudoaneurysms. We wish to report a case of pseudoaneurysm of the hepatic artery secondary to pancreatitis.

A forty-years-old man with a long history of alcohol abuse, recurrent gastrointestinal bleeding and chronic pancreatitis was admitted with multiple episodes of epigastric pain and hematemesis. His abdominal physical examination revealed a tender mass in the region of the right hypochondrium. No bruit was present. Serum alkaline phosphatase and serum amylase levels were high. Upper GI endoscopy revealed Grade-2 esophageal varices.

US of the abdomen demonstrated a cystic mass near the porta hepatis with thick, irregular echogenic walls. Color Doppler US revealed a turbulent arterial signal within this mass, consistent with a pseudoaneurysm. Contrast enhanced CT showed a mass at the porta hepatis eroding into the adjacent gall bladder. Enhancement within the centre of the mass during the arterial phase was strongly suggestive of a pseudoaneurysm of the hepatic artery [Figure - 1]. Digital subtraction angiography of the celiac trunk revealed a saccular pseudoaneurysm arising from the proximal and posterior aspect of the right hepatic artery [Figure - 2]. Two days after angiography, the patient developed a acute hypotensive episode and abdominal distension. An emergency laparotomy was performed and it showed massive intraperitoneal hemorrhage and a 10.0 cms sized saccular pseudoaneurysm of the right hepatic artery eroding into the gall bladder. Aneurysm repair was done. However, bleeding continued post-operatively due to consumptive coagulopathy and the patient died shortly after the surgery.

The hepatic artery is the fourth most common site of an intra-abdominal aneurysm from any cause following the infrarenal aorta, iliac and splenic arteries [1]. Of all patients with hepatic artery aneurysm, 80% have catastrophic rupture, either into the peritoneal cavity, billiary tree, duodenum, stomach or portal vein [1]. Eighty percent of hepatic artery aneurysms are extra-hepatic and of these, 63% affect the common hepatic artery, 5% the left hepatic artery and 4% the right and left hepatic arteries [2]. Lesions may be single or multiple. The average age at the time of diagnosis is thirty-eight years, 65% of cases occurring in men [3].

Pseudoaneurysm formation in pancreatitis is thought to occur because of autodigestion of the arterial wall by pancreatic enzymes, especially elastase, liberated due to pancreatitis. Although angiography remains the 'gold standard' for detection of pseudoaneurysms, US and CT are often diagnostic. More traditional methods of imaging may suggest the diagnosis by demonstrating a ring-like calcification in the right upper quadrant on plain films or an extrinsic mass defect on the duodenum during barium studies. PTC/ERCP may demonstrate extrinsic compression of the common bile duct. US detects pseudoaneurysms because of their pulsatile nature, except when perianeurysmal fibrosis or thrombosis is present. In the latter instance, Doppler imaging may reveal turbulent arterial flow consistent with pseudoaneurysm formation [4]. CT requires bolus injection of intravenous contrast material followed by immediate scanning for optimal visualization of these vascular abnormalities. The demonstration of a homogeneously enhancing structure within or adjacent to a pseudocyst or contiguous with a vascular structure is highly suggestive of an associated pseudoaneurysm [5]. This was seen in our patient. Although CT will not demonstrate the erosive vascular changes seen on arteriograms, it may demonstrate hemorrhage or pseudoaneurysm formation and indicate the necessity for obtaining an arteriogram. Angiography is usually reserved for those patients shown to have pancreatitis complicated by hemorrhage, occult blood loss or a pulsatile mass or is used preoperatively for patients with chronic pancreatic disease.

US and CT scanning may provide an early mechanism for identifying patients with pseudoaneurysms occurring consequent to pancreatitis. Otherwise diagnosis is usually made late in the course of disease when severe or even fatal hemorrhage may have occurred. We believe that greater radiologic awareness of this entity, together with recent improvements in US and CT imaging, will enable earlier detection of pseudoaneurysms that complicate pancreatitis.

 
   References Top

1.Cahow CE, Gusberg RJ, Gottlieb LJ. Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic pseudocysts. Am J Surg 1983; 145: 534-541.   Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Guida PM, Moore SW. Aneurysm of the hepatic artery: report of five cases with a brief review of the previously reported cases. Surgery 1966; 49: 51-54.   Back to cited text no. 2    
3.Croom RD, Frantz PT, Thomas CG, Hothem AL. Aneurysms of the hepatic artery. South Med J 1976; 69: 1013-1016.   Back to cited text no. 3    
4.Falkoff GE, Taylor KJW, Morse S. Hepatic artery pseudoaneurysm: diagnosis with real tie and pulsed Doppler ultrasound. Radiology 1986; 158: 55-56.   Back to cited text no. 4    
5.Burke JW, Erickson SJ, Kellum CD, Tegtmeyer CJ, Williamson RJ, Hansen MF. Pseudoaneurysms complicating pancreatitis; detection by CT. Radiology 1986; 161: 447-450.  Back to cited text no. 5    

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Correspondence Address:
Shekhar M Banavali
Department of Radiodiagnosis, Kasturba Medical College, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


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