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Year : 2003  |  Volume : 13  |  Issue : 3  |  Page : 311-313
Case report : Pseudoaneurysm from gastroduodenal artery associated with chronic pancreatitis; an unusual complication


Department of Radio-diagnoses, Gujarat Cancer and Research Institute, Asarwa Ahmedabad-380016, India

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Keywords: Chronic Pancreatitis, Psuedoaneurysm, Gastroduodenal Artery, CT Scan

How to cite this article:
Patel S B, Shah S R, Shah S S, Patel H B, Jain S, Kumar N A. Case report : Pseudoaneurysm from gastroduodenal artery associated with chronic pancreatitis; an unusual complication. Indian J Radiol Imaging 2003;13:311-3

How to cite this URL:
Patel S B, Shah S R, Shah S S, Patel H B, Jain S, Kumar N A. Case report : Pseudoaneurysm from gastroduodenal artery associated with chronic pancreatitis; an unusual complication. Indian J Radiol Imaging [serial online] 2003 [cited 2020 May 26];13:311-3. Available from: http://www.ijri.org/text.asp?2003/13/3/311/28706

   Introduction Top


An uncommon but important complication associated with chronic pancreatitis is formation of pseudoaneurysm. It is known to have very low incidence upto 10%. The most common artery affected by pseudoaneurysm is splenic artery. Next in the frequency are gastroduodenal and pancreaticodudenal arteries followed by left gastric, hepatic and small intrapancreatic arteries [1]. Although patient may develop palpable epigastric mass, bleeding and pain, they are often fully asymptomatic, being incidentally picked up on abdominal US, CT or angiography for other reasons. We report a case of Pseudoaneurysm from gastroduodenal artery, an unusual complication of chronic pancreatitis.


   Case Report Top


A fifty-five years old man presented with complaint of epigastric pain for three to fourth months. Patient had no complaints of hemetemesis or malena. Patient was taking alcohol since last fifteen years. US examination of abdomen was performed at our institute which revealed changes of chronic pancreatitis in the head of pancreas with presence of well-defined anechoic cystic lesion above head of pancreas. CT Scan of upper abdomen was performed at our institute on Hitachi CT W 2000 spiral CT scanner. Plain CT Scan at the level of head of pancreas [Figure - 1] shows changes of chronic pancreatitis in form of specks of calcification and irregular margins with presence of well defined hypodense lesion just above the head of the pancreas and medial to duodenum. CECT at the level of coeliac trunk [Figure - 2] shows normal splenic and common hepatic artery. CECT just below coeliac trunk at the level of head of pancreas [Figure - 3] shows early contrast filling of the lesion. Subsequent images [Figure - 4] shows complete contrast filling of the lesion with surrounding hypondensity. Thus diagnosis of Pseudoaneurysm arising from the gastroduodenal artery with partial thrombosis was considered. He was then operated for the same where above diagnosis was confirmed and pseudoaneurysm was ligated and resected.


   Discussion Top


Pseudoaneurysm is a known but uncommon complication of pancreatitis with incidence of 10% [1]. The dilatation that does not affect all layers of the vessel wall is called Pseudoaneurysm. It may occur in pancreatitis cases without association with pseudocyst or abscess [2]. Splenic artery is the most common artery to be involved and almost in half of the cases (30 to 50%) it is involved by Pseudoaneurysm [3],[4]. This is because of its close proximity to pancreas. It runs along pancreatic bed to reach spleen. Next in frequency are the gastroduodenal (10 to 15%) and pancreaticodudenal arteries (10%) [1]. followed by left gastric, hepatic and small intrapancreatic arteries. The pathogenesis of these aneurysms is poorly understood. There are probably two types of aneurysms associated with pancreatitis although they cannot be differentiated. If the inflammatory process causes partial digestion of arterial wall with loss of elastic tissue, it results in focal dilatation of vessel forming true aneurysms. False aneurysms are thought to occur due to incorporation of artery within wall of pseudocysts; with digestion of the artery wall the vessel ruptures into the pseudocyst converting it into pseudoaneurysm.

Although it may be asymptomatic, but the patients with pseudoaneurysm often suffer from the pain in the upper abdomen, or have gastrointestinal or peritoneal bleeding and anemia. Coeliac trunk aneurysms have the lowest rupture incidence (approx-2%) among all localizations of visceral artery aneurysm [5]. Bleeding due to pseudoaneurysm is most commonly reported in bowel followed by the peritoneal cavity, pancreatic duct or biliary tree. Pancreas is a retroperitoneal organ which lies within the C-loop of the duodenum laterally and the lesser sac anteriorly and encases the distal end of the common bile duct. This explains why the pseudoaneurysm can erode and bleed into the bowel, biliary tree, retroperitoneum, or peritoneal cavity.

The presence of pseudoaneurysm is mostly suspected on grey-scale US scan, while color-Doppler ultrasound successfully indicates the vascular nature of the mass. Typical grey-scale US features of pseudoaneurysm include anechoic mass with posterior acoustic enhancement, possibly with hyperechoic margins [6]. This presentation lacks specificity and mismatch with pancreatic pseudocyst has to be avoided. Pulsations of the mass may indicate the correct diagnosis, even when color Doppler US is not available. Rapid enlargement of the mass is, however, suggestive of a vascular lesion. Blood flow in pseudoaneurysm is usually easily detectable on color Doppler US [7]. Doppler analysis may be unreliable in obese individuals with deeply located lesions, in patients having tenderness on probe contact or in thin patients with marked aortic pulsations. A faint blood jet is sometimes detectable only with power Doppler, but one has to beware of false positive results due to motion artefacts. Typical CT finding of pseudoaneurysm include a well-defined mass with a hyperdense centre that shows contrast enhancement and a less dense periphery corresponding to mural clot and fibrous wall [2]. Angiography is fundamental for confirming diagnosis and exact location of aneurysm [4].

Although occasional reports have alluded to the spontaneous thrombosis of some pancreatic pseudoaneurysms, the current consensus holds that all these malformations should be treated to prevent the complication of bleeding. Nonsurgical management consists of transarterial catheter angioembolization with or without endoscopic stent placement. Angioembolization is considered much less invasive than surgery. The procedure can be completed quickly and is comfortable for the patient. It also allows the performance of surgery under optimal conditions [8]. Surgical approach is another modality of treatment.

 
   References Top

1.Arnold Friedman. Radiology of the liver, biliary tract, pancreas and spleen. 1987:674   Back to cited text no. 1    
2.Burke WJ, Erickson JS, Kellum DC et al. Pseudoaneurysm complicating pancreatitis: Detection by ct. radiology 1986; 161: 447-450   Back to cited text no. 2    
3.White ERF, Baum S, Suranasir S: Aneurysms secondary to pancreatitis. AJR 1976; 127: 393-396.   Back to cited text no. 3    
4.Walter JF, Chaung VP, Bookstein JJ, Reuter SR, Cho KJ, Pulmano CM: Angiography of massive heamorrhage secondary to pancreatic disease. Radiology 1977; 124: 337-342.   Back to cited text no. 4    
5.Stanley JC, Zelenock GB.Splanchnic artery aneurysms. In: Rutherford RB, editor. Vascular Surgery. Philadelphia: W.B.Saunders Company; 1995.p.1124- 8   Back to cited text no. 5    
6.Chiou AD, Joseph LG, Menzojan JO. Inferior pancreaticoduodenal artery aneurysms: report of a case and review of a literature. J Vasc Surg 1993; 17: 784-9   Back to cited text no. 6    
7.Kahn LA, Kamen C, McNamara MP Jr. Variable color-Doppler appearance of pseudoaneurysms in pancreatitis. Am J Roentgenol 1994; 162:187-8   Back to cited text no. 7  [PUBMED]  
8.McDermott VG, Schlansky-Goldb erg R, Cope C. Endovascular management of splenic artery aneurysms and pseudoaneurysms. Cardiovasc Intervent Radiol 1994; 17: 179-84  Back to cited text no. 8    

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Correspondence Address:
S B Patel
Department of Radio-diagnoses, Gujarat Cancer and Research Institute, Asarwa, Ahmedabad-380016
India
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Source of Support: None, Conflict of Interest: None


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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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