E0052 - A Case of Ruptured Gastroduodenal Artery Pseudoaneurysms in a Patient With Chronic Pancreatitis

Tuesday, October 25, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Haider Ghazanfar, MD

Bronxcare Health System
Bronx, NY

Haider Ghazanfar, MD, Abhilasha Jyala, MD, Sameer Kandhi, MD, Dongmin Shin, MD, Kazi Samsuddoha, MD, Harish Patel, MD
Bronxcare Health System, Bronx, NY

Introduction: Pancreatic pseudoaneurysm is a rare vascular complication of pancreatitis, with an estimated prevalence of 10%. Pseudoaneurysm can result from trauma, inflammation, infection, and iatrogenic causes. Due to its weak structural support, the risk of rupture is higher for pseudoaneurysm than that of a true aneurysm of similar size. Pancreatic pseudoaneurysms can lead to life-threatening complications such as rupture and bleeding, with increased morbidity and mortality up to 90% in untreated patients and 12.5% despite treatment. Due to its high mortality rate with rupture, pseudoaneurysms should be treated immediately once it is identified, regardless of their size or whether it is symptomatic or not

Case Description/Methods: We present a case of a 68 year old male patient with a past medical history significant for chronic pancreatitis who presented with altered mental status and hypovolemic shock secondary to unexplained gastrointestinal and retroperitoneal hemorrhage. Computed tomography (CT) Angiography was done which showed an enlarging retroperitoneal and right-sided intraperitoneal hematoma with suspicion for active arterial extravasation or punctate pseudoaneurysms in the pancreatic head. Celiac angiogram was done under fluoroscopic guidance, which showed gastroduodenal and superior pancreaticoduodenal artery pseudoaneurysms. He underwent successful endovascular coil embolization of the gastroduodenal artery. Post procedure he was monitored in intensive care unit. His clinical condition continued to improve and was discharged to a skilled nursing facility in stable condition.

Discussion: Physicians should be aware of pancreatic pseudoaneurysms as rare vascular complication associated with chronic pancreatitis that may lead to fatal gastrointestinal or retroperitoneal bleeding with a high mortality rate. Our case highlights the importance of early diagnosis and prompt treatment in these patients.

Figure: A: CT abdomen and pelvis without intravenous contrast showing peripancreatic inflammation surrounding the pancreatic body and head along with retroperitoneal bleed (red arrow). Pancreatic calcifications present (yellow arrow) signifying radiologic evidence of chronic pancreatitis
B: CT Angiography showing retroperitoneal and right-sided intraperitoneal hematoma with active arterial extravasation or punctate pseudoaneurysms in the pancreatic head.

Investigation	Day 1 of Hospitalization	Day 5	At Time of Discharge	Reference Range
White Blood Cell count	24.3	14.3 k/uL	7 k/uL	4.8-10.8 k/uL
Red Blood Cell Count	4.77	2.69 MIL/uL	3.19 MIL/uL	4.50-5.90 MIL/uL
Hemoglobin	15.8	8.5 mg/dl	10.2 mg/dl	12.0-16.0 g/dL
Hematocrit	47.6	25.7 %	30.5%	42-51 %
Platelet count	171	155 k/uL	215 k/uL	150-400 k/uL
Sodium, Serum	132	139 mEq/L	140 mEq/L	135-145 mEq/L
Potassium, Serum	3.0	3.2 mEq/L	3.9 mEq/L	3.5-5.0 mEq/L
Blood Urea Nitrogen, Serum	41	17 mg/ml	10 mg/ml	8-26 mg/dL
Creatinine, Serum	1.2	0.5 mg/dl	0.6 mg/dl	0.5-1.5 mg/dL
Bilirubin, Serum total	0.5	0.7 mg/dl	0.3 mg/dl	0.2-1.1 mg/dL
Serum Direct Bilirubin	0.3	0.3 mg/dl	< 0.2 mg/dl	0.0-0.3 mg/dL
Alkaline Phosphatase	51	48 units/L	73 units/L	56-155 unit/L
Aspartate Transaminase	125	21 units/L	18 units/L	9-48 unit/L
Alanine Aminotransferase	81	30 units /L	12 units /L	5-40 unit/L
Lactic acid Level	8.2	0.8 mmoles/L	1.1 mmoles/L	0.5-1.6 mmoles/L
Prothrombin Time	15.2	13.9 sec	10.5 sec	9.9-13.3 seconds
International Normalized Ratio	1.31	1.20	0.92	0.85-1.14
Serum Calcium	6.6mg/dl	7.6 mg/dl	9.2 3 mg/dl	8.5-10.5 mg/dl
Serum Lipase	24 U/L			< =61U/L
Serum Triglyceride	163mg/gl			55-150 mg/dl
Serum Ethanol	< 10			< = 10mg/dl
Urine Toxicology	Cocaine and methadone			Negative

Table: Laboratory Investigation

Disclosures:

Haider Ghazanfar indicated no relevant financial relationships.

Abhilasha Jyala indicated no relevant financial relationships.

Sameer Kandhi indicated no relevant financial relationships.

Dongmin Shin indicated no relevant financial relationships.

Kazi Samsuddoha indicated no relevant financial relationships.

Harish Patel indicated no relevant financial relationships.

Haider Ghazanfar, MD, Abhilasha Jyala, MD, Sameer Kandhi, MD, Dongmin Shin, MD, Kazi Samsuddoha, MD, Harish Patel, MD. E0052 - A Case of Ruptured Gastroduodenal Artery Pseudoaneurysms in a Patient With Chronic Pancreatitis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.