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Pancreaticoduodenal Arterial Aneurysms

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Pancreaticoduodenal Arterial Aneurysms Pancreaticoduodenal Arterial Aneurysms MICHAEL J. VERTA, JR., M.D., RICHARD H. DEAN, M.D.,* JAMES S. T. YAO, M.D., PH.D., JULIUS CONN, JR., M.D., W. HARRISON MEHN, M.D., JOHN J. BERGAN, M.D. Experience with four aneurysms of the pancreaticoduodenal From the Department of Surgery, Northwestern artery is reviewed and compared to the reported experience of University Medical School, 303 East Chicago Avenue, 19 other cases. In view of the common presentation of such Chicago, Illinois lesions as intra-abdominal hemorrhage preceded by non- specific abdominal pain and other digestive symptoms, it is sug- gested that angiography performed preoperatively or intra- operatively allows definitive diagnosis and leads to specific could have allowed a definitive diagnosis to be made therapy. prior to rupture of the aneurysm. These were unavail- able at the time that this patient was being treated in the A LTHOUGH aneurysms of the pancreaticoduo- mid- 1950's. denal artery are uncommon, the catastrophic mode of presentation of these lesions requires urgent Case 2. A 73-year-old man with a past history of severe athero- sclerotic cardiovascular disease, arthritis, and a seizure disorder was surgical care. Availability of selective catheter admitted to the Emergency Room of the Northwestern Memorial arteriography allows prompt definitive diagnosis which Hospital with a 6-week history of abdominal bloating, pain and aids in selecting appropriate surgical management of eructation. A sudden onset of abdominal pain and fainting had these lesions. occurred just prior to admission. A recent previous upper gastro- The preoperative diagnosis has rarely been made in intestinal series, cholecystogram, and barium enema had shown no abnormalities. the past and, now that angiography allows an accurate The patient was found to be in shock with cyanosis, cold, clammy diagnosis to be made, this review of cases presenting extremities, and an unobtainable blood pressure; pulse, 50 and regu- at the Northwestern University McGaw Medical lar. The abdomen was distended and rigid. Rapid infusion of Center has been made in order to formulate a plan for crystalloid and colloid solutions raised the blood pressure to 70/50. diagnosis and treatment. A lateral abdominal roentgenogram showed aortic calcification without aneurysm formation. Continued intravenous infusions were given as the patient was Case Reports taken to the operating suite. Exploration of the abdomen revealed Case 1. A 69-year-old man was seen at the Northwestern University free peritoneal blood, a large retroperitoneal hematoma extending Medical Center Hospitals with a three-year history of dysphagia, into the small bowel mesentery. Medial mobilization of the duo- weight loss and chest pain. A very large Zenker's diverticulum was denum revealed the inferior pancreaticoduodenal artery aneurysm, diagnosed, the patient was prepared for surgical correction by fluid which had ruptured into the peritoneal and retroperitoneal spaces. and blood volume replacement, and diverticulectomy was performed Postoperatively, the convalescence was complicated by recurrent successfully. On postoperative day 12, the patient vomited coffee- gastrointestinal bleeding, respiratory insufficiency, pneumonia, brown material twice. Nasogastric suction and intravenous fluids congestive heart failure and pleural effusions. Improvement was were instituted. In 48 hours, the patient experienced right upper slow until the 27th postoperative day, when the patient died quadrant pain, hypotension, tachycardia and abdominal distension. suddenly. Autopsy revealed an acute anterolateral myocardial in- Treatment with blood transfusions and intravenous fluids was un- farction. successful and autopsy revealed a ruptured aneurysm of the superior pancreaticoduodenal artery with retroperitoneal and free peritoneal Comment. Although this patient was seen at a time hemorrhage, as well as a duodenal wall hematoma. when sophisticated diagnostic techniques were avail- able, the presence of acute circulatory collapse and Comment. In this case, techniques of definitive of catheter such as shock prevented use emergency arteriog- diagnosis of upper gastrointestinal bleeding raphy. In a less urgent situation, this might have been with a contrast esophagogastroscopy combined performed. Similarly, when conventional contrast swallow and possibly supplemented by angiography studies failed to reveal the cause of a patient's 6-week- old complaints, consideration may have been given to Submitted for publication June 7, 1976. and the diagnosis of pan- Supported in part by the Northwestern University Vascular splanchnic arteriography Research Fund. creaticoduodenal artery aneurysm could have been * Current address: Vanderbilt University Medical Center. made. 111 112 VERTA AND OTHERS Ann. Surg. * July 1977 cholecystogram did not visualize the gallbladder. No abdominal masses or abnormal calcifications were seen. Surgical exploration revealed acute calculous cholecystitis as well as a large retroperitoneal hematoma. Medial mobilization of the duodenum revealed a ruptured aneurysm of the inferior pancreatico- duodenal artery. This was treated by aneurysmectomy, followed by an uneventful cholecystectomy. The postoperative course was complicated by a minor cerebro- vascular accident but recovery from this as well as the surgical pro- cedure was gradual and complete. Comment. This case demonstrates diagnostic dif- ficulties because of the presence of two simultaneously occurring pathologic processes, the contribution of either of which to the overall clinical picture is im- possible to assess. Had exploration not revealed so promptly the source of the hematoma, intra-operative visceral angiography by hand injection would have been the next logical step. Discussion FIG. 1. Diagram illustrating location of the pancreaticoduodenal Although aneurysm formation of minor visceral aneurysms described in the text. arteries is uncommon and rupture of these aneurysms is even less common, these lesions do exist and their Case 3. A 53-year-old woman was admitted to the Northwestern University Medical Center Hospitals because of sudden onset of effects upon patients are devastating. In an 80-year diffuse, severe abdominal pain. The pain had begun in the right period, up to 1975, 19 aneurysms of the pancreatico- upper quadrant when she lifted a heavy object and had persisted over duodenal artery were reported.9 Review of these cases a 12-hour period. During this time, the patient had fainted twice. (Table 1) indicates that non-specific abdominal pain, The past history was negative except for treatment of sigmoid often occurring in the right upper quadrant, is a com- diverticulitis. Physical examination was unrevealing. The hematocrit mon rupture was 36% and the white blood count, 15,300. During the physical characteristic. Symptoms precede frank of examination, the patient fainted and her blood pressure became the aneurysm in nearly every case. Rupture of the unobtainable. She was taken to the operating suite while blood aneurysm eventually creates manifestations of shock volume replacement was begun. but the bleeding is most commonly into the retro- Surgical exploration revealed a large free accumulation of blood in peritoneal or intraperitoneal space rather than into the the peritoneal cavity and a large hematoma extending into the small bowel and colonic mesenteries. Medial mobilization ofthe duodenum gastrointestinal tract. There are reports ofbleeding into revealed a ruptured aneurysm of the inferior pancreaticoduodenal the pancreatic duct25 and bleeding secondary to a artery. This was treated by aneurysmectomy and the patient re- penetrating duodenal ulcer,' but these are uncommon. covered slowly but uneventfully. Since symptoms precede onset of catastrophic hemorrhage, it is logical to assume that diagnostic tech- Comment. The 12-hour period of symptoms follow- niques can be employed to make preoperative and ing acute rupture of the pancreaticoduodenal artery prerupture diagnosis. That this is true is proven by the aneurysm indicates that time was available in this as report of Spanos22 and by analysis of the four cases well as the previous two cases for proper preoperative from the Northwestern University Medical Center. evaluation by diagnostic techniques that are presently Aneurysms of the pancreaticoduodenal artery occur available. to a great extent in patients in the arteriosclerotic age group and are associated with peripheral athero- Case 4. A 64-year-old man was seen at the Northwestern Univer- sclerosis (Table 1). Theoretically, such small visceral Medical Center Hospitals with a history of epigastric and upper sity aneurysms may be associated with other arterial abdominal pain radiating to the back, associated with nausea and vomiting. The pain increased following a meal of lamb chops and dysplasias and indeed, Shallow21 demonstrated ap- coffee, and spread to the lower quadrants. There was no prior history parent failure of fusion of the media and adventitia of of peptic ulcer disease. the arterial bifurcations of visceral aneurysms, indicat- Physical examination revealed an elderly Caucasiani man in obvious ing that this was a similar situation to that seen in intra- distress. He was unable to find a comfortable position in bed. There cranial berry aneurysms. This report has not been con- was tenderness and guarding which was poorly localized in the right upper quadrant. Laboratory examination revealed a white blood firmed by other investigators. Further substantiating
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