Pseudoaneurysm of the Gastroduodenal Artery Arising Within a Pancreatic Pseudocyst Jeffrey S. Bender, MD, F A C S , Marc A. Levison, MD, F A C S , Detroit,
Michigan
A case is presented of a 41-year-old man admitted for obstructive jaundice. Work-up revealed a pseudocyst of the pancreatic head which contained a large pseudoaneurysm of the gastroduodenal artery. After an unsuccessful attempt at embolization, the patient was treated with an uncomplicated pancreaticoduodenectomy. (Ann Vasc Surg 1992;6:171-172). KEY WORDS:
Pseudoaneurysm; pancreatic pseudocyst.
Chronic pancreatitis is accompanied by a visceral artery p s e u d o a n e u r y s m in approximately 10% of cases [1]. While often asymptomatic, these can manifest themselves by upper gastrointestinal hemorrhage. The proliferation of noninvasive testing methods and the increasing safety of arteriography make the preoperative diagnosis of a pseudoaneurysm more c o m m o n . We report here an unusual presentation in which a large p s e u d o a n e u r y s m of the gastroduodenal artery was found within a pseudocyst of the pancreatic head. Treatment required a pancreaticoduodenectomy.
CASE REPORT A 41-year-old man with a long history of alcohol abuse presented to our hospital with obstructive jaundice. He was admitted and a computerized tomographic (CT) scan showed a large pancreatic phlegmon. He was placed on total parenteral nutrition and managed expectantly. Follow-up CT scan two weeks later showed some resolution of the phlegmon, but the beginning of a pseudocyst. His jaundice gradually resolved. He was unable to tolerate an
From the Department of Surgery, Detroit Receiving Hospital and Wayne State University, Detroit, Michigan. Reprint requests: Jeffrey S. Bender, MD, FACS, Francis Scott Key Medical Center, Department of Surgery, 4940 Eastern Avenue, Baltimore, Maryland 21224.
oral diet. A C T scan done five weeks post-admission showed a five centimeter pseudocyst of the pancreatic head containing what appeared to be a large vascular structure. This was interpreted as a possible pseudoaneurysm (Fig. 1). Early the next morning, the patient vomited bright red blood. He remained hemodynamically stable. An esophagogastroduodenoscopy failed to reveal a source and the hemorrhage was judged to be a sentinel bleed from the pseudoaneurysm. An emergency arteriogram was obtained which showed a gastroduodenal artery pseudoaneurysm (Fig. 2). Embolization was undertaken, but was not successful in abolishing the pseudoaneurysm because of collateral flow. The patient was taken to the operating room the following day and a pylorus-sparing pancreaticoduodenectomy was performed. Sectioning of the specimen showed that the coil used for embolization was in the gastroduodenal artery within the substance of the pancreas. Clot was present in the pseudocyst. The patient had no further gastrointestinal hemorrhage and had an uneventful postoperative course. He was discharged home on the twelfth postoperative day. At follow-up three weeks later he was on a regular diet and was taking no medications. He has not kept further appointments.
DISCUSSION The term " h e m o s u c c u s p a n c r e a t i c u s " was coined by Sandblum in 1970 for use in cases of bleeding through the pancreatic duct into the gas-
171
172
P S E U D O A N E U R YSM OF THE GASTRODUODENAL A R T E R Y
Fig. 1. Computed tomographic scan showing pseudoaneurysm arising within a pancreatic pseudocyst. trointestinal tract [2]. While initially thought to be quite rare [3], the expansion of medical technology has led to the recognition that this syndrome can explain many previously obscure cases of upper gastrointestinal hemorrhage [4,5]. Pseudoaneurysms associated with pancreatic
Fig. 2. Selective arteriogram demonstrating pseudoaneurysm of gastroduodenal artery.
mmm
ANNALS OF VASCULAR SURGERY
pseudocysts are presumed to be caused by erosion into the vessel by the expanding pseudocyst. In our case, the pseudoaneurysm was demonstrated to be within the pseudocyst proper. While it is tempting to speculate that the pseudoaneurysm arose or started to bleed because of autodigestion, there is no laboratory or other experimental evidence to support this. Exact treatment of a bleeding pseudocyst located within the pancreatic head is controversial. These patients are often unstable and control of hemorrhage must be given the highest priority. Ligation of vessels may not prevent future hemorrhage because of the proliferation of collateral vessels in this area. This was illustrated in our case by the failure of embolization to control the pseudoaneurysm. Indeed, the literature shows a rebleeding rate of 30% when oversewing alone is attempted, with a subsequent mortality of 75% for those who require reoperation [6]. Emergency pancreaticoduodenectomy for a bleeding pancreatic pseudocyst has been done with no reported mortality and minimal morbidity. This experience mirrors the improvement in results for pancreaticoduodenectomy when done for malignancy [7].
REFERENCES 1. WHITE AF, BAUM S, BURANASIRI S, Aneurysms secondary to chronic pancreatitis. A m J Roentgenol 1986;127: 393-396. 2, SANDBLUM P. Gastrointestinal hemorrhage through the pancreatic duct. Ann Surg 1970;171:61-66. 3. HARRIS RD, ANDERSON JE, COEL MN. Aneurysms of the small pancreatic arteries: a cause of upper abdominal pain and intestinal bleeding. Radiology 1975;115:17-20. 4. CAHOW CE, GUSBERG RJ, GOTTL1EB LJ. Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic pseudocysts. A m J Surg 1983;145:534-541. 5. STABILE BE, WILSON SE, DEBAS HT. Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis. Arch Surg 1983;118:45-51. 6. BENDER JS, LEVISON MA. Massive hemorrhage associated with pancreatic pseudocyst: successful treatment by pancreaticoduodenectomy. A m Surg 1991;57:653--655. 7. CRIST DW, SITZMANN JV, CAMERON JL. Improved hospital morbidity and mortality after the Whipple procedure. Ann Surg 1987;206:358-365.
Michigan
A case is presented of a 41-year-old man admitted for obstructive jaundice. Work-up revealed a pseudocyst of the pancreatic head which contained a large pseudoaneurysm of the gastroduodenal artery. After an unsuccessful attempt at embolization, the patient was treated with an uncomplicated pancreaticoduodenectomy. (Ann Vasc Surg 1992;6:171-172). KEY WORDS:
Pseudoaneurysm; pancreatic pseudocyst.
Chronic pancreatitis is accompanied by a visceral artery p s e u d o a n e u r y s m in approximately 10% of cases [1]. While often asymptomatic, these can manifest themselves by upper gastrointestinal hemorrhage. The proliferation of noninvasive testing methods and the increasing safety of arteriography make the preoperative diagnosis of a pseudoaneurysm more c o m m o n . We report here an unusual presentation in which a large p s e u d o a n e u r y s m of the gastroduodenal artery was found within a pseudocyst of the pancreatic head. Treatment required a pancreaticoduodenectomy.
CASE REPORT A 41-year-old man with a long history of alcohol abuse presented to our hospital with obstructive jaundice. He was admitted and a computerized tomographic (CT) scan showed a large pancreatic phlegmon. He was placed on total parenteral nutrition and managed expectantly. Follow-up CT scan two weeks later showed some resolution of the phlegmon, but the beginning of a pseudocyst. His jaundice gradually resolved. He was unable to tolerate an
From the Department of Surgery, Detroit Receiving Hospital and Wayne State University, Detroit, Michigan. Reprint requests: Jeffrey S. Bender, MD, FACS, Francis Scott Key Medical Center, Department of Surgery, 4940 Eastern Avenue, Baltimore, Maryland 21224.
oral diet. A C T scan done five weeks post-admission showed a five centimeter pseudocyst of the pancreatic head containing what appeared to be a large vascular structure. This was interpreted as a possible pseudoaneurysm (Fig. 1). Early the next morning, the patient vomited bright red blood. He remained hemodynamically stable. An esophagogastroduodenoscopy failed to reveal a source and the hemorrhage was judged to be a sentinel bleed from the pseudoaneurysm. An emergency arteriogram was obtained which showed a gastroduodenal artery pseudoaneurysm (Fig. 2). Embolization was undertaken, but was not successful in abolishing the pseudoaneurysm because of collateral flow. The patient was taken to the operating room the following day and a pylorus-sparing pancreaticoduodenectomy was performed. Sectioning of the specimen showed that the coil used for embolization was in the gastroduodenal artery within the substance of the pancreas. Clot was present in the pseudocyst. The patient had no further gastrointestinal hemorrhage and had an uneventful postoperative course. He was discharged home on the twelfth postoperative day. At follow-up three weeks later he was on a regular diet and was taking no medications. He has not kept further appointments.
DISCUSSION The term " h e m o s u c c u s p a n c r e a t i c u s " was coined by Sandblum in 1970 for use in cases of bleeding through the pancreatic duct into the gas-
171
172
P S E U D O A N E U R YSM OF THE GASTRODUODENAL A R T E R Y
Fig. 1. Computed tomographic scan showing pseudoaneurysm arising within a pancreatic pseudocyst. trointestinal tract [2]. While initially thought to be quite rare [3], the expansion of medical technology has led to the recognition that this syndrome can explain many previously obscure cases of upper gastrointestinal hemorrhage [4,5]. Pseudoaneurysms associated with pancreatic
Fig. 2. Selective arteriogram demonstrating pseudoaneurysm of gastroduodenal artery.
mmm
ANNALS OF VASCULAR SURGERY
pseudocysts are presumed to be caused by erosion into the vessel by the expanding pseudocyst. In our case, the pseudoaneurysm was demonstrated to be within the pseudocyst proper. While it is tempting to speculate that the pseudoaneurysm arose or started to bleed because of autodigestion, there is no laboratory or other experimental evidence to support this. Exact treatment of a bleeding pseudocyst located within the pancreatic head is controversial. These patients are often unstable and control of hemorrhage must be given the highest priority. Ligation of vessels may not prevent future hemorrhage because of the proliferation of collateral vessels in this area. This was illustrated in our case by the failure of embolization to control the pseudoaneurysm. Indeed, the literature shows a rebleeding rate of 30% when oversewing alone is attempted, with a subsequent mortality of 75% for those who require reoperation [6]. Emergency pancreaticoduodenectomy for a bleeding pancreatic pseudocyst has been done with no reported mortality and minimal morbidity. This experience mirrors the improvement in results for pancreaticoduodenectomy when done for malignancy [7].
REFERENCES 1. WHITE AF, BAUM S, BURANASIRI S, Aneurysms secondary to chronic pancreatitis. A m J Roentgenol 1986;127: 393-396. 2, SANDBLUM P. Gastrointestinal hemorrhage through the pancreatic duct. Ann Surg 1970;171:61-66. 3. HARRIS RD, ANDERSON JE, COEL MN. Aneurysms of the small pancreatic arteries: a cause of upper abdominal pain and intestinal bleeding. Radiology 1975;115:17-20. 4. CAHOW CE, GUSBERG RJ, GOTTL1EB LJ. Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic pseudocysts. A m J Surg 1983;145:534-541. 5. STABILE BE, WILSON SE, DEBAS HT. Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis. Arch Surg 1983;118:45-51. 6. BENDER JS, LEVISON MA. Massive hemorrhage associated with pancreatic pseudocyst: successful treatment by pancreaticoduodenectomy. A m Surg 1991;57:653--655. 7. CRIST DW, SITZMANN JV, CAMERON JL. Improved hospital morbidity and mortality after the Whipple procedure. Ann Surg 1987;206:358-365.
