Visceral Arterial Aneurysms Complicating Endoscopic Retrograde Cholangiopancreatography

Abstract

We report this case of a 74-year-old man with altered anatomy secondary to Billroth-II surgery who underwent endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis and subsequently developed severe diffuse abdominal pain with drop in hemoglobin. Patient was found to have hemorrhagic shock requiring aggressive resuscitative measures. Patient was found to have large peripancreatic hematoma secondary to bleeding from gastroduodenal and superior pancreaticoduodenal artery pseudoaneurysms. Gastroduodenal artery aneurysm is the rarest of all the splanchnic artery aneurysms, and to our knowledge this is the only reported case of a gastroduodenal artery pseudoaneurysm complicating ERCP.

Angiographic management of pseudoaneurysms of gastroduodenal artery following endoscopic sphincterotomy

“…In our patients, bleeding was due to pseudoaneurysms in the branches of the gastroduodenal artery. This is rare, and a search in Pubmed revealed one previously reported case following a nontherapeutic ERCP [2]. Hypothetical mechanisms include direct injury to the vessel wall, ischemic injury due to diathermy current or secondary to ERCP-induced pancreatitis, and the pseudoaneurysm can develop as early as 2 days after ERCP [2].…”

“…This is rare, and a search in Pubmed revealed one previously reported case following a nontherapeutic ERCP [2]. Hypothetical mechanisms include direct injury to the vessel wall, ischemic injury due to diathermy current or secondary to ERCP-induced pancreatitis, and the pseudoaneurysm can develop as early as 2 days after ERCP [2]. The patient developed pseudoaneurysm after developing acute pancreatitis and was managed successfully with angioembolization.…”

“…It should be kept in mind while dealing with a severe hemorrhage as standard endoscopic methods to control bleeding may not be successful. Angioembolization is considered the first-line treatment for this complication, failing which surgery may be required [2]. Various agents used for embolization are coils, glue, ethylene vinyl alcohol, absorbable gelatin-compressed sponge, polyvinyl alcohol particles, and Amplatzer vascular plugs.…”

“…Secondary hemorrhage from pseudoaneurysms developed in the branches of the gastroduodenal artery is a rarely reported cause of post-sphincterotomy bleeding [2]. Although postsphincterotomy bleeding is usually handled by the endoscopists themselves by various hemostatic methods, pseudoaneurysms are usually managed by angiointervention [2]. We report two cases of secondary hemorrhage from pseudoaneurysm of gastroduodenal artery occurring secondary to endoscopic sphincterotomy.…”

“…Rarely, significant bleeding may occur during the procedure or several days later secondary to the injury to the branches of the gastroduodenal artery. Secondary hemorrhage from pseudoaneurysms developed in the branches of the gastroduodenal artery is a rarely reported cause of post-sphincterotomy bleeding [2]. Although postsphincterotomy bleeding is usually handled by the endoscopists themselves by various hemostatic methods, pseudoaneurysms are usually managed by angiointervention [2].…”