Ruptured Splenic Artery Pseudoaneurysm Causing Hemorrhage Into a Pancreatic Pseudocyst

Abstract

This case report describes fatal exsanguination due to splenic artery hemorrhage into a pancreatic pseudocyst with cystogastrostomy in a 46-year-old woman. The decedent had a complicated medical history including necrotizing pancreatitis, giant pseudocyst formation after cystogastrostomy procedure, and coiling of a hemorrhagic splenic artery. While hospitalized, she underwent embolization of a ruptured splenic artery pseudoaneurysm. Weeks later, she went into hemorrhagic shock and was ultimately pronounced at the hospital. Doctors suspected an upper gastrointestinal (GI) bleed as the cause of death; however, the patient was too unstable to undergo interventional radiology at the time.At autopsy, the pancreas was hemorrhagic and included a 15 Â 15 Â 15-cm pseudocyst, which contained a metallic stent from a cystogastrostomy. This case describes a unique co-occurrence of numerous common complications of chronic pancreatitis. There are multiple ways by which pancreatitis can cause upper and lower GI bleeds. In this case, the presence of a cystogastrostomy stent allowed for a ruptured pseudoaneurysm to hemorrhage through the pancreatic pseudocyst and into the stomach and duodenum, mimicking the presentation of a more common upper GI bleed. The pseudocyst then ruptured causing abdominal hemorrhage. The passage of hemorrhage through a cystogastrostomy stent is not described in other literature.

Rupture of Splenic Artery Pseudoaneurysm with Pancreatitis: A Rare Case Report

“…It can lead to contained hematoma when active extravasation stops. A flank rupture of pseudoaneurysm can result in massive bleeding into the intraperitoneal cavity (9).…”

Giant Pseudoaneurysm of the Splenic Artery: Size/Rupture Correlation

“…About 15% of patients were healthy with an unknown etiology. Of the three cases of giant splenic artery PSA following operation, one case was following splenectomy due to idiopathic thrombocytopenia [ 10 ], one following pancreatoduodenectomy procedure [ 11 ] and one case following cyst-gastrostomy operation [ 12 ]. Twenty patients (50%) presented with rupture of the PSA, manifested by bleeding either into the GI tract, into the abdominal cavity or by bloody discharge in the abdominal drains.…”

“…Seventeen patients (42.5%) presented with abdominal pain, two patients with upper abdominal fullness and pulsation and one patient with general deterioration ( Table 1 ). Of the group of patients presenting with rupture, three cases of mortality (15%) were reported [ 12 , 16 , 17 ], two of which while waiting for endovascular intervention in the hospital at the surgical ward and the third [ 12 ] was due to massive GI re-bleeding weeks following endovascular intervention.…”