Indian Journal of Radiology Indian Journal of Radiology  

   Login   | Users online: 328

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size     

 

LETTER TO EDITOR Table of Contents   
Year : 2000  |  Volume : 10  |  Issue : 3  |  Page : 189-191
Splenic arteriovenous fistula following penetrating injury to abdomen


Indore, India

Click here for correspondence address and email
 

How to cite this article:
Tyagi A, Kapoor N. Splenic arteriovenous fistula following penetrating injury to abdomen. Indian J Radiol Imaging 2000;10:189-91

How to cite this URL:
Tyagi A, Kapoor N. Splenic arteriovenous fistula following penetrating injury to abdomen. Indian J Radiol Imaging [serial online] 2000 [cited 2019 Sep 15];10:189-91. Available from: http://www.ijri.org/text.asp?2000/10/3/189/30599
Sir,

Splenic arteriovenous fistula (AVF) is a known but rare complication of trauma [1]. There is a direct association between the injury to the pancreas or surgical dissection in the pancreatic bed and the development of (AVF). In this patient, a documented penetrating upper abdominal injury resulted in the development of a splenic AVF besides pseudo-pancreatic cyst.

A twenty-five-years-old man was admitted to the emergency ward with complaints of vomiting of coffee colored fluid mixed with fresh blood. He gave a history of exploratory laparotomy fourteen months earlier, for penetrating nail injury to the upper abdomen. The details of the previous operation showed that a nail had perforated the anterior and posterior walls of the stomach and entered the pancreas [Figure - 1]. The pancreatic injury had been bleeding and hemostasis was achieved by suturing. Post-operative recovery was uneventful except for mild pancreatitis. The patient was discharged seven days later with normal liver functions.

Clinical examination revealed a scar of the surgical operation in the epigastric region with a palpable thrill. There was a machinery murmur on auscultation. Blood investigations and liver function tests were normal except for a Hb level of 10 gm. Serological markers for HbsAg were negative.

CT of the upper abdomen showed a large pseudopancreatic cyst and multiple torturous vessels on its left side [Figure - 2]. At upper gastro-intestinal endoscopy many blood clots in the stomach were observed leading to poor visibility. Angiography was performed through selective injection of the celiac trunk. There was immediate visualization of dilated splenic, portal and inferior mesenteric veins and a large arteriovenous malformation. Extensive gastric varices were also seen [Figure - 3]. A diagnosis of splenic AVF leading to portal hypertension was confirmed. The patient underwent another exploratory laparotomy with resection of the fistula, pseudopancreatic cyst and splenectomy. Post-operative recovery was uneventful. Follow up endoscopy was normal.

Blunt or penetrating injury to the abdomen leading to splenic AVF is well described in the literature [1],[2]. This case was unique because a documented penetrating injury led to fistula formation within fourteen months, besides the development of a pseudopancreatic cyst. The other notable causes of splenic AVF described in the literature are high intra-abdominal pressure such as pregnancy and childbirth [2], post splenectomy [3] and following rupture of a splenic artery aneurysm into the splenic vein [1]. The development of portal hypertension in patients with splenic AVF could be related to an increase in intravenous pressure resulting from increased blood flow or arterialization of the portal venous system. This is a potentially treatable entity and splenectomy with resection of fistula resulted in resolution of signs and symptoms in all reported cases [4] as was the case in our patient. The patient had had no follow-up after initial surgery therefore it was difficult to assess the duration of the pseudopancreatic cyst. This cyst might have been present for a long time probably after initial surgery and gradually became larger. Presence of pseudopancreatic cyst for such a long duration without complications is also unusual and the extent of its contribution to the formation of the AVF is uncertain [5]. The most probable cause of splenic AVF in this patient appears to be injury either to the splenic artery or vein during initial surgery. The AVF evolved over a long time after initial trauma or surgery. Increased venous pressure of the splenic vein and portal vein led to formation of gastric varices and dilatation of the inferior mesenteric vein, which drains into the splenic vein.

We also believe that normal liver function or biopsy in patients with portal hypertension should be followed up by Doppler sonography [6] and angiography [7] to visualize any splanchnic AVF. Selective catheterization of celiac and mesenteric vessels [8] should be included in the study. A history of abdominal trauma, splenectomy, multiple pregnancies and presence of splenic artery aneurysm are strong indicators. Suggestive clinical features include a pulsatile or soft mass in the upper abdomen with palpable thrill and machinery murmur on auscultation. The ideal treatment in selected patients would be to embolize the arteriovenous fistula. Embolization was not considered in our case because of the large size of the AVF [1].

 
   References Top

1.Campbell D, Geraghty JG, McNicholas MM, Murphy JJ. Delayed presentation of traumatic splenic arterio-venous fistula. Ir Med J 1991; 84: 129-130.   Back to cited text no. 1  [PUBMED]  
2.Arida EJ. Splenic arteriovenous fistula with portal hypertension, varices and ascites N.Y. State J Med 1977; 77L 787-790.   Back to cited text no. 2    
3.Lacobe M, Hannoun L. Arteriovenous fistula of splenic vessels after splenectomy. J Chir Paris 1984; 121: 159-162.   Back to cited text no. 3    
4.Braga AM, Baldacci MP, Caruso S et al . Fistola artero-venosa splenica (union caso clinico). Chir Ital 1992; 44: 174-179.   Back to cited text no. 4    
5.Stephen FQ, Reed F, Alexander R, Charles GP. Splenic artery pseudoaneurysm after placement of percutaneous transgastric catheter for a pancreatic pseudocyst. AJR 1988; 151: 495-496.   Back to cited text no. 5    
6.Cantarero JM, Llorente JG, Hidalgo EG, Hualde A, Ferreiro R. Splenic arteriovenous fistula: Diagnosis by duplex doppler sonography (letter). AJR 1989; 153: 1313-1314.   Back to cited text no. 6  [PUBMED]  
7.Shleapnik M, Shiptz B, Siegal A, Dinbar A. Bleeding esophageal varices and portal hypertension caused by arteriovenous fistula of splenic artery. HPB Surg. 1990; 3: 53-56.   Back to cited text no. 7    
8.Capron JP, Gineston JL, Alexandre R et al . Inferior mesenteric arteriovenous fistula associated with portal hypertension and acute ischemic colitis. Gastroenterology 1984; 86: 351-355.  Back to cited text no. 8    

Top
Correspondence Address:
Ashok Tyagi
Indore
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions


    Figures

[Figure - 1], [Figure - 2], [Figure - 3]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed3384    
    Printed89    
    Emailed0    
    PDF Downloaded0    
    Comments [Add]    

Recommend this journal