Massive Upper Gastrointestinal Bleeding from a Splenic Artery Pseudoaneurysm Caused by a Penetrating Gastric Ulcer: Case Report and Review of Literature

Abstract

SummaryBackgroundSplenic artery aneurysm and pseudoaneurysm are rare pathologies. True aneurysms are usually asymptomatic. Aneurysm rupture occurring in 2–3% of cases results in bleeding into the lesser sack, peritoneal space or adjacent organs typically presenting as abdominal pain and hemodynamic instability. In contrast, pseudoaneurysms are nearly always symptomatic carrying a high risk of rupture of 37–47% and mortality rate of 90% if untreated. Therefore, prompt diagnosis and treatment are essential in the management of patients with splenic artery pseudoaneurysm. Typical causes include pancreatitis and trauma. Rarely, the rupture of a pseudoaneurysm presents as upper gastrointestinal (UGI) bleeding. Among causes, peptic ulcer is the casuistic one.Case ReportThis report describes a very rare case of recurrent UGI bleeding from a splenic artery pseudoaneurysm caused by a penetrating gastric ulcer. After negative results of endoscopy and ultrasound, the diagnosis was established in CT angiography. The successful treatment consisted of surgical ligation of the bleeding vessel and suture of the ulcer with preservation of the spleen and pancreas, which is rarely tried in such situations.ConclusionsThe most important factor in identifying a ruptured splenic artery pseudoaneurysm as a source of GI bleeding is considering the diagnosis. UGI hemorrhage from splenic artery pseudoaneurysm can have a relapsing course providing false negative results of endoscopy and ultrasound if performed between episodes of active bleeding. In such cases, immediate CT angiography is useful in establishing diagnosis and in application of proper therapy before possible recurrence.

Splenic artery aneurysm as a rare cause of an upper GIT bleed

“…Endoscopy may reveal cases with complications such as gastric or colonic fistula, although these findings may be falsely negative or misinterpreted. Sawacki et al presented a case report of a patient who, much like our case, presented with an UGIB and had an initial negative endoscopy 8. Following a negative ultrasound the diagnosis was eventually made on CT angiography 8.…”

Tratamento endovascular da hemorragia digestiva aguda por volumoso pseudoaneurisma esplênico: relato de caso e revisão da literatura

“…Although PASA is the most common type of visceral aneurysm, it is still a rare entity. 1,11 If it is not treated promptly, the risk of rupture is in the range of 37-47% 12,13 and the mortality rate is 90%. 5,12,13 In the case described here, the patient was admitted because of symptoms related to PASA rupture: upper digestive hemorrhage with hemodynamic instability.…”

“…[13][14][15][16] The most common causes of PASA include local inflammatory states (primarily chronic and acute pancreatitis) and trauma. 4,5,[11][12][13]17 Tessier et al 4 reported associations with pseudocysts in 41% of cases of pancreatic PASA. Among other less frequent causes, Hartman et al 17 described a PASA associated with scleroderma and gastric ulcer, with no history of pancreatitis.…”

“…It is believed that the pathophysiology of PASA can be explained in three ways: in cases of pancreatic or peripancreatic inflammation, the wall of the SA is thought to undergo digestion by pancreatic enzymes, with consequent weakening of the artery wall 4,18,19 ; in trauma, the second most common cause, the rapid deceleration would result in damage to the intima and the elastic layer of the SA, predisposing it to formation of a pseudoaneurysm 4,10,18 ; and in cases related to pancreatic pseudocysts, these may erode the artery wall and cause a fistula from the artery to the mucosa of the gastrointestinal tract or the interior of the pseudocyst. 12,18 In chronic pancreatitis, in addition to occurrence of PASA, the most common form (40%), other arteries may also be involved, such as the gastroduodenal artery (30%); the pancreaticoduodenal artery (20%); the left gastric artery (5%); and the common hepatic artery (2%). 18 In an article containing case reports and a review of the literature, Tessier et al 4 list the most common symptoms as gastrointestinal hemorrhage and abdominal pains.…”

A splenic artery aneurysm presenting with multiple episodes of upper gastrointestinal bleeding: a case report

“…A few cases of possibly true SAAs with intragastric bleeding were reported, but the histologic confirmation of them being true aneurysms was not confirmed [17, 18]. Unlike true SAAs, intragastric bleeding is a common feature of pseudoaneurysms of the splenic artery [19, 20]. A rare case of a splenic artery pseudoaneurysm fistulating into the transverse colon was reported by O’Brien et al [21].…”