E0322 - Spontaneous Sub-Diaphragmatic Hemorrhage From Aneurysm of Inferior Phrenic Artery due to Segmental Arterial Mediolysis

Venkata Pulivarthi, MD¹, Yamini Katamreddy, MD², Sai Swarupa Vulasala, MBBS³, Jayabharath Onteddu, MBBS⁴, Saikiran Mandyam, MBBS, MD⁵, Nirmal Onteddu, MBBS, MD^6
1Creighton University School of Medicine, Phoenix, AZ; ²West Anaheim Medical Center, Anaheim, CA; ³East Carolina Health Medical Center, Greenville, NC; ⁴Viswabharathi Medical College, Kurnool, Andhra Pradesh, India; ⁵South East Health, Dothan, AL; ⁶Flowers Hospital, Dothan, AL

Introduction: Visceral artery aneurysms and pseudoaneurysms are uncommon but potentially lethal clinical entities. Inferior phrenic artery (IPA) involvement is very rare (< 1%) compared to splenic and hepatic artery involvement. Common etiology for IPA pseudoaneurysm being post traumatic or iatrogenic from catheter-based procedures. The other etiologies include sepsis, vasculitis, collagen vascular diseases, and Segmental Arterial Mediolysis (SAM). We report a diagnosis and management of a rare case of spontaneously ruptured IPA pseudoaneurysm.

Case Description/Methods: 50-year-old male presented with one-day history of epigastric and left upper quadrant abdominal pain. Review of symptoms positive for unintentional weight loss of 20lbs in the past six weeks. Medical history is significant for hypertension, untreated Hepatitis C infection, intravenous drug abuse, and smoking. No history of pancreatitis, blunt trauma, abdominal surgery, and alcohol use. On examination, his vitals were stable, diminished left lung base breath sounds and epigastric and LUQ abdominal tenderness without peritoneal signs. Laboratory workup showed elevated WBC count, Creatinine 1.15 mg/dl, mildly elevated ALT and AST, positive Hepatitis C antibody and normal lipase level and coagulation panel. The urine drug screen was positive for methamphetamine and opioids. CT with contrast (Fig a,b) showed active bleeding at gastric cardia with posterior mediastinal and distal esophagus/gastric cardia hypodensity concerning for hematoma. Small volume, high-density fluid along the greater curvature of the stomach compatible with hemoperitoneum. He underwent esophagogastroduodenoscopy revealing no active bleed. Subsequently, he underwent a celiac, left gastric, splenic, multilevel intercostal, and IPA angiogram (Fig c). A pseudoaneurysm of the left IPA with contrast extravasation was identified, and embolized using Coil and gel foam.

Discussion: Diagnosis of SAM involves clinical, laboratory, and imaging findings but gold standard being histological diagnosis. Clinical presentation, the vessels involved, and the presence of end-organ ischemia determine the management of SAM. Surgical management was first-line historically for any patient presenting with acute intra-abdominal bleeding. With the advancement of minimally invasive technologies, emergent catheter angiography and endovascular intervention, has become the first line in a hemodynamically stable patient.



Disclosures:


Venkata Pulivarthi, MD¹, Yamini Katamreddy, MD², Sai Swarupa Vulasala, MBBS³, Jayabharath Onteddu, MBBS⁴, Saikiran Mandyam, MBBS, MD⁵, Nirmal Onteddu, MBBS, MD⁶. E0322 - Spontaneous Sub-Diaphragmatic Hemorrhage From Aneurysm of Inferior Phrenic Artery due to Segmental Arterial Mediolysis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.