University of Pittsburgh Medical Center Homestead, PA, United States
Abdelrhman M. Abo-Zed, MD1, Amitha Avasarala, MD2, Harkirat Singh, MD2 1University of Pittsburgh Medical Center, Pittsburgh, PA; 2UPMC Mercy, Pittsburgh, PA
Introduction: Pancreaticoduodenal artery aneurysms or pseudoaneurysms (PDAA) are uncommon amongst splanchnic artery aneurysms. We present an unusual case of PDAA presenting as painless obstructive jaundice.
Case Description/Methods: 77-year-old female presented with generalized itching and jaundice. Two months prior, she had an admission after sustaining a mechanical fall, and was found to have with a C2, T4 and T7 fractures, and was managed conservatively. Her abdominal exam was unremarkable. Labs showed a total bilirubin of 13.1 mg/dL, direct bilirubin 9.8 mg/dL, Alkaline phosphatase 1372 u/L, ALT 530 u/L, and AST 361 u/L. CT scan of abdomen and pelvis showed a large aneurysm adjacent to the porta hepatis, measuring 4.4 x 3.7 cm, which compressed adjacant portal vein, and common bile duct, causing extra and intrahepatic biliary ductal dilation. Patient was taken for IR angiography and attempt at endovascular management. Celiac artery (CA) angiogram demonstrated occlusion of the common hepatic artery, and opacification of the gastroduodenal artery (GDA) and proper hepatic artery, via collaterals. The pseudoaneurysm was not visualized. Superior mesenteric artery angiogram showed that the large pseudoaneurysm arose with inflow from the inferior PDA. At least one outflow was seen with opacification of the right hepatic artery. Due to vessel tortuosity, the inferior PDA was unable to be accessed with guidewires and catheters. She underwent surgery with ligation of GDA and inferior PDA, which both appeared to feed the aneurysm. Post-operatively her LFTs trended down. A repeat CT on post-operative day 8 showed areas of liver infarctions involving segments 3, 4B, 5 and 6, with bilomas. Serial abdominal CT scans showed improvement in bilomas, and regression of the aneurysm. At the last follow up, eight months into clinical course, a CT angiogram showed no aneurysm, and a normal liver.
Discussion: Majority of PDAA are associated with either severe stenosis or obstruction of the celiac axis, which was not present in our patient. We hypothesize that the finding of common hepatic artery thrombosis is the likely etiology of aneurysm pathogenesis in our case. Presentation with obstructive jaundice also differentiates our case with the usual presentations of abdominal pain or a bleeding. A multidisciplinary approach was followed in managing our patient, which is recommended in these patients with higher risk of morbidity and mortality.
Figure: Coronal view of aneurysm, with CBD compression.
Disclosures: Abdelrhman Abo-Zed indicated no relevant financial relationships. Amitha Avasarala indicated no relevant financial relationships. Harkirat Singh indicated no relevant financial relationships.
Abdelrhman M. Abo-Zed, MD1, Amitha Avasarala, MD2, Harkirat Singh, MD2. P1114 - A Rare Vascular Cause of Obstructive Jaundice, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.