Dilatation of the Bile and Pancreatic Ducts Due to Compression by an Unruptured Abdominal Aortic Aneurysm (AAA): a Case Ameliorated by an Endovascular Stent Grafting

□ CASE REPORT □

Dilatation of the Bile and Pancreatic Ducts due to Compression by an Unruptured Abdominal Aortic Aneurysm (AAA): A Case Ameliorated by an Endovascular Stent Grafting

Toshiro Fukui, Ryo Suzuki, Yutaku Sakaguchi, Nobuyuki Shibatani, Daisaku Hachimine, Kazushige Uchida, Akiyoshi Nishio, Toshihito Seki and Kazuichi Okazaki

Abstract

An 88-year-old woman was referred to our hospital due to abdominal discomfort. Imaging modalities showed an abdominal aortic aneurysm (AAA) compressing the duodenum, the distal common bile duct and the head of the pancreas concurrent with distension of the proximal bile and main pancreatic ducts in the body and tail of the pancreas. After admission, the patient underwent endovascular stent grafting to treat the AAA. The size of the aneurysm decreased and the dilatation of the bile and pancreatic ducts became less prominent. AAA should therefore be considered as a possible diagnosis in patients with findings of dilatation of the bile ducts in the absence of stones or tumors in the pancreaticobiliary system. This is the first reported case of a patient treated for both AAA and dilatation of the bile and pancreatic ducts with endovascular stent grafting via the femoral artery.

Key words: dilatation of bile and pancreatic ducts, abdominal aortic aneurysm (AAA), endovascular stent grafting

(Intern Med 51: 2749-2752, 2012) (DOI: 10.2169/internalmedicine.51.8294)

via the femoral artery without undergoing abdominal aortic Introduction aneurysmectomy.

Abdominal aortic aneurysms (AAAs) are often asympto- Case Report matic and are not discovered until the time of rupture. Ex- panding AAAs have been reported to produce compression An 88-year-old woman was referred to our hospital for of several vital abdominal structures, including the urinary evaluation of vague and non-specific upper abdominal dis- tract (1), bowel (2-4) and vascular trunks (5). The most comfort. She had a surgical history of cholecystectomy 30 common gastrointestinal complication of AAA is rupture years previously and was taking only amlodipine besilate (5 into the duodenum with massive hemorrhage and mg/day) for systemic hypertension. Systematic questioning shock (2, 6, 7). On the other hand, expanding or ruptured revealed no discernible risk factors for the development of AAAs rarely cause bile duct compression (2, 6-14). This re- primary biliary (or liver) or pancreatic disease and the pa- port describes our experience with an unusual case of tient had never been jaundiced. At the initial visit, the pa- marked dilatation of the bile and pancreatic ducts due to tient had a blood pressure of 132/71 mmHg and heart rate compression by an unruptured AAA. To the best of our of 78 beats/min. Blood tests revealed no abnormal changes knowledge, this is the first reported case of a patient safely in liver enzymes, prothrombin time or the levels of total se- and effectively treated for both AAA and dilatation of the rum bilirubin, albumin, serum amylase and hemoglobin (Ta- bile and pancreatic ducts with endovascular stent grafting ble). A physical examination revealed a pulsatile mass in the

The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Japan Received for publication June 3, 2012; Accepted for publication July 10, 2012 Correspondence to Dr. Toshiro Fukui, [email protected]

2749 Intern Med 51: 2749-2752, 2012 DOI: 10.2169/internalmedicine.51.8294

Figure 2. At magnet resonance cholangiopancreatography, no filling defects were identified within the common bile duct. However, the distal common bile duct and the main pancreatic Figure 1. A contrast computed tomography (CT) scan dem- duct in the head of the pancreas were smoothly narrow and onstrating an abdominal aortic aneurysm compressing the du- deviated laterally by the abdominal aortic aneurysm. Addi- odenum, the distal common bile duct (a) and the head of the tionally, distension of the proximal bile duct and the main pancreas (b). Considerable mural thrombus was present. (a) pancreatic duct in the body and tail of the pancreas was ap- Arrows and arrowheads indicate the aneurysm and the com- parent. Arrows and arrowheads indicate the common bile mon bile duct, respectively. (b) Arrows and arrowheads indi- duct and the main pancreatic duct, respectively. cate the aneurysm and the main pancreatic duct, respectively.

was present. At magnet resonance cholangiopancreatogra- Table. Blood Test at the Initial Visit phy, no filling defects were identified within the CBD itself. However, the distal CBD and the MPD in the head of the pancreas were smoothly narrow and deviated laterally by the AAA, and distension of the proximal bile duct and the MPD in the body and tail of the pancreas were apparent (Fig. 2). Taking into account these findings and the proximity of the aneurysm to the duodenum and the distal CBD, we decided not to perform endoscopic retrograde cholangiopancreatography to insert a biliary stent at that time. The patient was di- agnosed with dilatation of the bile and pancreatic ducts re- sulting from compression of the region of the pancreas head by an AAA developing from the abdominal aorta below the renal artery. We regarded the AAA as an indication for endovascular stent grafting after consultation with the patient, her family and the vascular surgeon. For two months after her initial visit, the patient’s blood tests showed no abnormal changes in liver enzymes or the levels of bilirubin, amylase and hemoglobin. After admission to our hospital, she underwent endovascular stent grafting to treat the infrarenal AAA. Her postoperative course was uneventful, and she was discharged on the 9th postoperative day. upper abdomen; however, neither the liver nor the spleen One year after the operation, the size of the AAA was was palpable. The patient was not icteric. All peripheral ar- found to have decreased (Fig. 3b) compared with that ob- terial pulses were present. served before surgery (Fig. 3a). Although the AAA com- An abdominal ultrasound study showed significant dilata- pressing the distal CBD remained, dilatation of the proximal tion of the intra-hepatic bile duct, the common hepatic duct bile duct (Fig. 3d) and the MPD in the body and tail of the and the main pancreatic duct (MPD) in the body and tail of pancreas (Fig. 3f) was less prominent than that observed in the pancreas. In addition, the patient had an AAA measuring the preoperative evaluation (Figs. 3c, 3e). The patient is cur- 7.5 cm long with a maximum diameter of 5.3 cm. A con- rently asymptomatic. trast computed tomography (CT) scan demonstrated the presence of an infrarenal AAA compressing the duodenum, Discussion the distal common bile duct (CBD) (Fig. 1a) and the head of the pancreas (Fig. 1b). A considerable mural thrombus The gastrointestinal complications of AAA primarily in-

2750 Intern Med 51: 2749-2752, 2012 DOI: 10.2169/internalmedicine.51.8294

Figure 3. CT scans obtained before (a, c, e) and after (b, d, f) surgery. The size of the abdominal aortic aneurysm decreased (b) compared with that observed before the operation (a). Although the abdominal aortic aneurysm compressing the distal common bile duct remained, dilatation of the proximal bile duct (d) and the main pancreatic duct in the body and tail of the pancreas (f) was less prominent than that observed in the preoperative evaluation (c, e).

volve rupture into the duodenum (2). Dilatation of the bile risk of rupture. In other previous cases (2, 6, 7, 11, 13, 14), and pancreatic ducts due to compression caused by an AAA however, no specific treatments, i.e. aneurysmectomy or en- is rare. According to PubMed searches (from 1949 to June dovascular stent grafting, were administered for unruptured 2012), only 10 previous cases have been reported in the aneurysms due to patient age, etc. In the present case, the English medical literature (2, 6-14). In seven of these cases unruptured AAA was safely and effectively treated with en- (2, 6, 7, 10, 11, 13, 14), direct pressure was applied to bile dovascular stent grafting via the femoral artery despite the ducts from unruptured aneurysms. In the remaining patient’s advanced age. The patient is currently in good cases (8, 9, 12), the bile duct compression was caused by health; however, she is under regular review by both general hematomas from extramural leakage. and vascular surgeons. We firmly believe that endovascular In our patient, dilatation of the MPD was also related to stent grafting is the best therapy for treating elderly patients pancreatic or sphincteric compression caused by the aneu- with AAAs that produces compression of the biliary and/or rysm. We are aware of only two previous reports of MPD pancreatic ducts. dilatation or pancreatitis due to unruptured aortic aneu- Endovascular stent grafting offers a significantly less inva- rysms (10, 14). sive alternative to conventional open surgical repair. Consid- The surgical repair of an unruptured aneurysm has been erable reductions in hospital stays and early returns to pre- attempted in only one previous report (10). In that case, operative levels of activity have been demonstrated in pa- emergency surgery was performed because the aneurysm tients who undergo endovascular stent grafting. Patients pre- rapidly increased in size and the patient had a significant viously considered unsuitable for open repair can often re-

2751 Intern Med 51: 2749-2752, 2012 DOI: 10.2169/internalmedicine.51.8294 ceive treatment for aneurysms with endovascular techniques. aortic aneurysm. N Y State J Med 70: 673-676, 1970. Despite the minimal invasiveness of this treatment, there are 4. Newmeyer W, Royster TS, Antenucci AJ. Duodenal compression by abdominal aortic aneurysms. Am J Gastroenterol 48: 63-66, unanswered questions as to the durability and efficacy of de- 1967. vices, which creates concerns about the ability of these de- 5. Lepke RA, Pagani JJ. Renal artery compression by an aortic aneu- vices to successfully protect patients from subsequent rup- rysm: an unusual cause of hypertension. AJR Am J Roentgenol ture (15). 139: 812-813, 1982. More common causes of compression and lateral devia- 6. Spinelli GD, Kleinclaus DH, Wenger JJ, Christmann DJ, Matter tion of the lower bile duct include pancreatic neoplasms, DF, Warter PC. Obstructive jaundice and abdominal aortic aneurysm: an ultrasonographic study. Radiology 144: 872, 1982. pancreatic cysts, pancreatic abscesses and acute and chronic 7. van Gossum A, Rubinstein M, Engelholm L, Cremer M. Common pancreatitis. There are also case reports of similar radiologi- bile duct compression by an abdominal aortic aneurysm. Endo- cal features with malignant lymphadenopathy around the scopy 18: 69-70, 1986. duodenum and cavernous transformation of the portal vein. 8. Hashmonai M, Stahl S, Schramek A. Rupture of an aortic abdomi- In the present case, we could have ruled out the possibility nal aneurysm presenting as painful obstructive jaundice. J Cardio- vasc Surg (Torino) 22: 187-189, 1981. of these conditions noninvasively using ultrasound studies, 9. Lieberman DA, Keeffe EB, Rahatzad M, Keller FS. Ruptured ab- contrast computed tomography and magnet resonance cho- dominal aortic aneurysm causing obstructive jaundice. Dig Dis Sci langiopancreatography. 28: 88-93, 1983. In conclusion, unruptured AAA should be considered as a 10. Dohi K, Fukuda Y, Nakagawa K, et al. A case of obstructive jaun- possible diagnosis in elderly patients with findings of dilata- dice due to abdominal aneurysm compression. Hiroshima J Med Sci 33: 819-823, 1984. tion of the bile and pancreatic ducts in the absence of any 11. van Someren N, Benson M, Jacomb-Hood J, Swain P. Aneurysmal evidence of stones or tumors in the pancreaticobiliary sys- dilation of the abdominal aorta: a rare cause of obstructive jaun- tem. We suggest performing endovascular stent grafting for dice. Gastrointest Endosc 39: 85-87, 1993. AAA in elderly patients with these findings. 12. Dorrucci V, Dusi R, Rombola G, Cordiano C. Contained rupture of an abdominal aortic aneurysm presenting as obstructive jaundice: report of a case. Surg Today 31: 331-332, 2001. The authors state that they have no Conflict of Interest (COI). 13. Smith AD, Mohammed F, Watson GM, Howlett DC. Common bile duct compression by an abdominal aortic aneurysm: an unusual cause of biliary tract dilatation. Eur J Gastroenterol Hepatol References 14: 767-769, 2002. 1. Culp O, Bernatz PE. Urologic aspects of lesions in the abdominal 14. Cowell D, Pover A, Buter A, Moug SJ. Education and Imaging. aorta. J Urol 86: 189-195, 1961. Hepatobiliary and pancreatic: bile duct dilatation caused by an 2. Sondheimer FK, Steinberg I. Gastrointestinal manifestations of ab- aortic aneurysm. J Gastroenterol Hepatol 25: 1467, 2010. dominal aortic aneurysms. Am J Roentgenol Radium Ther Nucl 15. Bush RL, Lin PH, Lumsden AB. Endovascular management of ab- Med 92: 1110-1122, 1964. dominal aortic aneurysms. J Cardiovasc Surg (Torino) 44: 527- 3. Panaro VA, Melzer MJ. Duodenal obstruction from abdominal 534, 2003.

2752