Hemorrhagic shock secondary to rupture of a right gastroepiploic artery aneurysm: Case report and brief review of splanchnic artery aneurysms

Abstract

A case of a 78-year-old woman who presented with hemorrhagic shock and abdominal pain, and who was subsequently found to have a ruptured aneurysm of the right gastroepiploic artery, is presented. She underwent open surgical resection of the aneurysm without any significant postoperative complication. A brief review of splanchnic artery aneurysms with regard to their incidence, presentation and approaches for repair is also presented.Key Words: Gastroepiploic artery; Splanchnic aneurysm CASE PRESENTATIONA case of a 78-year-old woman who was transported to the emergency room with mental status deterioration associated with hypotension and abdominal pain is presented. Her medical history was significant for hypertension, atrial fibrillation, dementia and a previous aortic valve replacement. She was being anticoagulated with coumadin for both her valve replacement and her atrial fibrillation. Physical examination showed the patient to have a pulse rate of 110 beats/min, blood pressure of 80/40 mmHg and normal temperature. She was alert, but lethargic and confused. Her abdominal examination showed a nondistended abdomen with diffuse tenderness. She did not have melenic stool or bright red blood per rectum, and there was no history of nausea or hematemesis. Laboratory evaluations were significant for hemoglobin of 7 g/L, a hematocrit of 22%, white blood cell count of 8×10 9 /L, and normal blood urea nitrogen and creatinine. Resuscitation measures were instituted, and the patient underwent a computed tomography scan of the abdomen and pelvis with oral and intravenous contrast (Figure 1). The images demonstrated a large (5.2 cm) ruptured aneurysm extending off the right greater curvature of the stomach with moderate hemoperitoneum. The patient was then taken to the operating room for an exploratory celiotomy. Approximately 2 L of blood were aspirated from the peritoneal cavity upon entry. The source of bleeding was found to be a ruptured aneurysm of the right gastroepiploic artery (GEA). The aneurysm was then resected following proximal and distal arterial control. Upon completion, the patient was noted to have a tear on the medial surface of the spleen with subsequent mild bleeding. Due to the need for postoperative anticoagulation for the patient's prosthetic valve, it was decided to perform a splenectomy. The patient was transferred to the surgical intensive care unit where she remained intubated for three days. She was transferred to the ward where she recovered without any postoperative complications until the time of discharge to a rehabilitation facility. A repeat computed tomography scan was performed ( Figure 1D) for a leukocytosis that showed complete resection of the aneurysm and no other pathology.

Ruptured gastroepiploic artery aneurysm: A case report

“…An endovascular approach has also been described [5] . In our case, and in others, when patients present in shock with a suggestion of aneurysm rupture, an urgent laparotomy is required for definitive management [2] .…”

“…Gastroepiploic artery aneurysms are rare lesions that require attention given their propensity to rupture. Unfortunately, most GEAAs are diagnosed once a complication arises [2] . These patients typically present with diffuse abdominal pain and shock relating to intraperitoneal hemorrhage.…”

“…Splanchnic artery aneurysms are overall, rare entities most commonly caused be atherosclerotic disease [1] . The most encountered subtypes include splenic, hepatic and superior mesenteric arterial aneurysms with a distribution of 35%, 23% and 19% respectively [2] . Gastroepiploic artery aneurysms (GEAA) make up only 3.5% of splanchnic artery aneurysms and are therefore rarely seen.…”

“…Gastroepiploic artery aneurysms (GEAA) make up only 3.5% of splanchnic artery aneurysms and are therefore rarely seen. However, the rate of rupture of GEAAs is reported to be as high as 90% and carries a 70% mortality [1] , [2] , [3] . A discussion of the management of these cases is thus warranted.…”

Posterior Gastric Artery Aneurysm

“…Revascularisation procedures were indicated only in special settings. 7 , 8 Presently, an endovascular approach after diagnostic CTA is the preferred method in most centres.…”