E0452 - A Rare Case of Inferior Pancreaticoduodenal Artery Pseudoaneurysm Rupture Following Endoscopic Retrograde Cholangiopancreatography

Tuesday, October 25, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Averill Guo, MD

The Warren Alpert Medical School of Brown University
Providence, RI

Averill Guo, MD¹, Amber Charoen, MD¹, Fadlallah Habr, MD²
¹The Warren Alpert Medical School of Brown University, Providence, RI; ²Warren Alpert Medical School of Brown University, East Providence, RI

Introduction: Hemorrhage is a known potential complication of endoscopic retrograde cholangiopancreatography (ERCP), often occurring at the site of sphincterotomy. Less commonly, intra- and retroperitoneal hemorrhage can occur secondary to splenic, hepatic, or vascular injury. Here we present a rare case of inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm (PSA) rupture following ERCP in a patient with a large diaphragmatic hernia.

Case Description/Methods: The patient is a 68 year old man with a history of hypertension, chronic kidney disease, and splenectomy. He presented with jaundice, fatigue, and labs notable for hypoglycemia, acidemia, acute kidney injury, normal transaminase levels, alkaline phosphatase (129 IU/L), total bilirubin (4.2 mg/dL), direct bilirubin (2.5 mg/dL), and lipase (157 IU/L). Computed tomography (CT) with contrast revealed choledocholithiasis with a 1.2 cm stone in the head of the pancreas associated with pneumobilia, intra- and extrahepatic ductal dilation, and pancreatic ductal dilation. A large left diaphragmatic hernia with protrusion of nonobstructed loops of large and small bowel into the left hemithorax was also noted. He underwent ERCP with biliary sphincterotomy and removal of one stone. One large stone remained. A plastic stent was placed in the common bile duct with plans to repeat ERCP in 4-6 weeks with cholangioscopy and electrohydrolic lithotripsy.

Following ERCP, the patient developed acutely worsening anemia without overt evidence of lumenal gastrointestinal bleeding. CT angiography revealed active extravasation and a PSA within an intra-abdominal hematoma (18.4 x 8.5 cm). The patient then underwent mesenteric angiography which showed one multilobulated (2 x 1.8 cm) and one smaller PSA arising from an IPDA branch. Coil embolization of the dominant PSA was performed, achieving hemostasis.

Discussion: Visceral artery aneurysm (VAA) rupture is an exceedingly rare complication of ERCP with IPDA pseudoaneurysms accounting for just 2% of VAA. Although there is a known association of VAA with pancreatitis, the mechanism for PSA formation following ERCP is unclear. It is thought to be associated with sphincterotomy with rupture caused by direct mechanical injury related to pancreaticobiliary manipulation. Mortality related to VAA rupture and hemorrhage can be as high as 19%. A high index of suspicion and early detection followed by angioembolization are critical for reducing mortality.

Figure: (A) CT with contrast showing choledocholithiasis with a 1.2 cm stone in the head of the pancreas. (B) CT angiography showing active extravasation and a pseudoaneurysm (PSA) within an intra-abdominal hematoma (18.4 x 8.5 cm). (C) Mesenteric angiography which showed one multilobulated (2 x 1.8 cm) and one smaller PSA arising from an inferior pancreaticoduodenal artery branch.

	Age/Sex	Comorbidities	ERCP Indication	Interventions	Symptom	Diagnosis	Treatment
Al-Jeroudi et al 2001	76 F	None	Palliation of pancreatic carcinoma	Precut sphincterotomy, biliary stent	Abdominal pain	IPDA PSA	Embolization
Rim et al 2021	27 M	Sickle cell disease	Choledocholithiasis	Sphincterotomy, stone extraction, biliary stent, pancreatic duct stent	Abdominal pain, acute anemia	IPDA PSA rupture	Embolization
Current Case	68 M	Hypertension, chronic kidney disease, diaphragmatic hernia	Choledocholithiasis	Sphincterotomy, stone extraction, biliary stent	Abdominal pain, acute anemia	IPDA PSA rupture	Embolization

Table: Summary of currently available case reports of inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm (PSA) development following endoscopic retrograde cholangiopancreatography (ERCP)

Disclosures:

Averill Guo indicated no relevant financial relationships.

Amber Charoen indicated no relevant financial relationships.

Fadlallah Habr indicated no relevant financial relationships.

Averill Guo, MD¹, Amber Charoen, MD¹, Fadlallah Habr, MD². E0452 - A Rare Case of Inferior Pancreaticoduodenal Artery Pseudoaneurysm Rupture Following Endoscopic Retrograde Cholangiopancreatography, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.