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Thrombosis of Splenic Artery Pseudoaneurysm Complicating Pancreatitis

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Thrombosis of Splenic Artery Pseudoaneurysm Complicating Pancreatitis Gut 1993; 34:1271-1273 1271 Thrombosis of splenic artery pseudoaneurysm complicating pancreatitis Gut: first published as 10.1136/gut.34.9.1271 on 1 September 1993. Downloaded from Th De Ronde, B Van Beers, L de Canniere, J P Trigaux, M Melange Abstract tory syndrome/erythrocyte sedimentation rate: The natural history of pseudoaneurysms 91 mm/h (normal <15), fibrinogen 7-44 g/l complicating pancreatitis is unknown. A (normal 1 80-4-00), and C reactive protein 120 patient with chronic pancreatitis is described mg/i (normal <7); a mild hyperleucocytosis was in whom thrombosis of a splenic artery seen at 12 6x109/1 (normal 4-10). Pancreatic pseudoaneurysm occurred. Early diagnosis enzymes were ofnormal values. and radical treatment of a bleeding pseudo- A computed tomography examination showed aneurysm are mandatory. When elective a pseudocyst, 3 cm in diameter, in the pancreatic treatment is considered, however, contrast head and several pseudocysts located behind the enhanced computed tomography may be use- body of the pancreas; a dilatation of the main ful just before surgery as thrombosis may pancreatic duct was seen in the tail. Endoscopic occur. retrograde pancreatQgraphy showed irregular (Gut 1993; 34: 1271-1273) dilatation of the main pancreatic duct in the tail and opacification ofthree pseudocysts, one in the head and two in the body of the pancreas. The Departments of Gastro- Arterial pseudoaneurysms are classic complica- patient stopped any alcohol intake but his pain Enterology, tions of pancreatitis, especially when pseudo- Th De Ronde worsened despite analgesics. M Melange cysts are present.' Bleeding pseudoaneurysms Three weeks later, a second CT examination may be life threatening and require early was performed. It showed an eccentric contrast Radiology, diagnosis and radical treatment. enhancing mass, 1 5 cm in diameter, within one B Van Beers We report on a case of thrombosis of a splenic J P Trigaux of the corporeal pseudocysts in which density artery pseudoaneurysm complicating chronic was increased (Fig 1). and General and pancreatitis. A coeliac and splenic angiography showed a Digestive Surgery, Cliniques Universitaires postostial pseudoaneurysm of the splenic artery UCL de Mont-Godinne, without active bleeding (Fig 2). Stable catheteri- Yvoir, Belgium Case report sation of the splenic artery near the ostium was L de Canniere A 43 year old man with several years' history of not possible, precluding transcatheter embolisa- http://gut.bmj.com/ Correspondence to: Dr Th De Ronde, Cliniques alcohol abuse and with chronic pancreatitis tion of the feeding artery. Selective catheterisa- Universitaires UCL de Mont- confirmed at endoscopic retrograde pancreato- tion of the pseudoaneurysm itself was not Godinne, B 5530 Yvoir, Belgium graphy presented in October 1990 for recrudes- attempted because of the risk of rupture. Accepted for publication cent epigastralgia. Clinical examination was Somatostatin infusion (Somatostatine UCB 250 5 January 1993 normal. Laboratory tests showed an inflamma- ,tg/h) was given to reduce pancreatic secretion and elective surgical intervention was decided on for the seventh day. on October 1, 2021 by guest. Protected copyright. Computed tomography, performed the day before planned surgery, showed a spontaneous hyperdensity and a lack of contrast enhancement of the pseudoaneurysm, suggesting recent thrombosis (Fig 3). A coeliac angiography con- firmed the thrombosis of the pseudoaneurysm and the permeability ofthe splenic artery (Fig 4). Computed tomography performed two months and one year later showed regression of the clotted pseudoaneurysm and progressive disappearance of the pseudocysts. Discussion Arterial pseudoaneurysms are not uncommon with acute or, more often, chronic pancreatitis especially when pseudocysts are present.' Pseudoaneurysms are caused by enzymatic digestion67 or local compression of the vessel by the pseudocyst.3 Because of its proximity to the pancreas, the splenic artery is the most com- monly affected vessel.346 Visceral pseudo- aneurysms are difficult to diagnose. They may be detected with computed tomography and duplex Figure 1: Computed tomography shows an eccentric contrast enhancing lesion, I 5 cm in diameter (straight arrow) within a retrocorporeal pseudocyst where density is increased. Another sonography, but selective angiography is still the pseudocyst is seen above the pancreatic head (curved arrow). diagnostic examination of choice."9 1272 De Ronde, Van Beers, de Cannie're, Trigaux, Melange Gut: first published as 10.1136/gut.34.9.1271 on 1 September 1993. Downloaded from Figure 2: Coeliac arteriogram shows a postostial pseudoaneurysm ofthe splenic artery (arrow). The main risk of visceral pseudoaneurysm is rupture and consecutive bleeding. This risk is much higher in pseudoaneurysms secondary to pancreatitis.""'I Bleeding can occur directly or through the pseudocyst, if present. This may cause secondary rupture in the main pancreatic duct, the peritoneum, the retroperitoneum or more often in an adjacent viscus such as duo- denum, stomach or transverse colon.' 3 6 12 13 Early diagnosis and radical treatment are thus mandatory. Surgery is the classic treatment of pseudoaneurysm but transcatheter arterial embolisation seems to be a very attractive alternative either to permit further elective surgery or as a definitive treatment with good results and a lower mortality than surgery.3 5 7 http://gut.bmj.com/ The incidence and natural history of pseudo- aneurysms complicating chronic pancreatitis is unknown. At angiography performed in patients with chronic pancreatitis without gastrointest- inal bleeding pseudoaneurysms have been seen in 10-21% of cases36774 but only 1-8% of gastro- intestinal bleedings in patients with pancreatic on October 1, 2021 by guest. Protected copyright. pseudocysts are thought to be pseudoaneurysm These Figure 3: Computed tomography performed nine days later shows a lack ofcontrast related.3 data suggest that not all pseudo- enhancement ofthe pseudoaneurysm, suggesting thrombosis. Notice the high enhancement ofthe aneurysms will lead to gastrointestinal haemor- aorta, the splenic artery (white arrow), and the hepatic artery (black arrow). rhage.3 Spontaneous regression of small visceral Figure 4: Coeliac arteriogram confirms the lack ofenhancement ofthe clottedpseudoaneurysm. (Arrows point to reflux ofcontrast material in the aorta.) Thrombosis ofsplenic arterypseudoaneurysm complicatingpancreatitis 1273 pseudoaneurysms has been reported, including investigations about somatostatin in this field pseudoaneurysms of the splenic artery. I5 Several could also be ofinterest. authors have thus recommended a conservative approach for asymptomatic patients with 1 El Hamel A, Parc R, Adda G, Bouteloup PY, Huguet C, Gut: first published as 10.1136/gut.34.9.1271 on 1 September 1993. Downloaded from Malafosse M. Bleeding pseudocysts and pseudoaneurysms visceral pseudoaneurysms smaller than 2 5 cm in in chronic pancreatitis. BrJ Surg 1991; 78: 1059-63. diameter, except for women of child bearing 2 Cahow CE, Gusberg RJ, Gottlieb LJ. Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic pseudo- age.'0 16 cysts. AmJ Surg 1983; 145: 534-41. Spontaneous early thrombosis of pseudo- 3 Forsmark CE, Wilcox CM, Grendell JH. Endoscopy-negative upper gastrointestinal bleeding in a patient with chronic aneurysms secondary to pancreatitis has not pancreatitis. Gastroenterology 1992; 102: 320-9. been described, however, except in one case 4 van Rooyen W, van Blankenstein M, Eeftinck Schattenkerk M, de Vries JE, Obertop H, Bruining HA, et al. Haemor- affecting the inferior pancreaticoduodenal rhage from the pancreatic duct: a rare form of upper artery."I Pseudoaneurysms complicating pan- gastrointestinal bleeding. BrJ Surg 1984; 71: 137-40. 5 Vujic I. Vascular complication of pancreatitis. Radiol Clin creatitis are thought to be the most life threaten- North Am 1989; 27: 81-91. ing ofall splanchnic artery aneurysms with death 6 Burke JW, Erickson SJ, Kellum CD, Tegtmeyer CJ, Williamson BRJ, Hansen MF. Pseudoaneurysms complicat- rate greater than 50%.'1 ing pancreatitis: detection by CT. Radiology 1986; 161: We have no clear explanation for the thrombo- 447-50. 7 Mandel SR, Jaques PF, Mauro MA, Sanofsky S. Nonopera- sis of the pseudoaneurysm in our case. It may be tive management of peripancreatitic arterial aneurysms. A related to the catheterisation of the coeliac trunk 10-year experience. Ann Surg 1987; 205: 126-8. 8 Kibbler CC, Cohen DL, Cruicshank JK, Kushwaha SS, and the splenic artery. Trauma during catheteri- Marsha y Morgan, Dick RD. Use of CAT scanning in the sation seems unlikely, however, because the diagnosis and management of hepatic artery aneurysm. Gut 1985; 26: 752-6. splenic artery remained permeable on follow up 9 Tobben PJ, Zaiko AB, Sumkin JH, Bowen A, Fuhrman CR, studies and catheterisation of the pseudo- Skolnick ML, et al. Pseudoaneurysms complicating organ transplantation: roles of CT, duplex sonography and angio- aneurysm was not performed. graphy. Radiology 1988; 169: 65-70. Somatostatin is known to reduce splanchnic 10 Stanley JC, Wakefield TW, Graham LM, Whitehouse WM, Zelenock GB, Lindenauer SM. Clinical importance and blood flow without modifying systemic arterial management of splanchnic artery aneurysms. J Vasc Surg blood pressure. 7 The mechanism ofaction is still 1986; 3:836-40. 11 Frey CF, Stanley JC, Eckhauser F. Hemorrhage. In: Bradley debated.'8 Some authors have suggested that EL, ed. Complications
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