Gastric subepithelial lesion (SEL) was commonly encountered during endoscopic procedure as an incidental finding. The estimated incidence of gastric SEL is approximately 1 in 300 patients. 1 For SEL, further stepwise investigation would be needed according to the size and location of the lesion. 2 However, splenic artery aneurysm is rare etiology of SEL but should be considered as a differential diagnosis for gastric SEL.
This 43‐year‐old male had postprandial abdominal fullness and intermittent epigastric cramping pain since couple of months ago after trauma. He went to local medical doctor (LMD) first and esophagogastroduodenoscopy (EGD) there revealed a 2–3‐cm SEL at posterior wall of high body (Figure 1(A)). Therefore, he was transferred to our out patient department (OPD) for further examination.
FIGURE 1.
(A) Esophageogastroduodenoscopy noted one 2–3‐cm subepithelial lesion (SEL) over posterior wall of high body. (B) An 2.1‐cm anechoic lesion without septum or solid component noted under EUS, favor external compression. (C) A 2.6 × 2.1 cm splenic artery aneurysm compressing posterior wall of gastric high body along greater curvature side. (D) Another 0.8 × 0.7 cm splenic artery aneurysm near splenic hilum, both lesions noted under arterial phase of CT. (E) Angiography demonstrated splenic aneurysm compatible with CT image
The result of laboratory tests was all in normal range. For further survey of the gastric SEL, endoscopic ultrasound (EUS) was performed with UM‐2R and water immersion method, which showed a 2.1‐cm homogeneous anechoic tumor arising from extramural location with well‐defined margin without septum, mural nodule, or calcification inside (Figure 1(B)). Because of external compression was highly suspected, contrast‐enhanced computerized tomography (CT) of abdomen was arranged for diagnosis. The CT scan revealed two splenic artery aneurysms under arterial phase, proximal one: 2.6 × 2.1 cm, near posterior wall of gastric high body, and distal one: 0.8 × 0.7 cm, near splenic hilum, respectively (Figure 1(C),(D)). Conclusively, the SEL of gastric high body was accidentally found seems resulting from external compression by splenic artery aneurysm.
The patient was then referred to the department of cardiovascular surgery for subsequent following up. Angiography was done for vascular structure evaluation (Figure 1(E)). Patient was asymptomatic. Because of borderline size of the aneurysm and the torturous of the vascular structure, close monitoring by CT angiography and abdominal echo every 6 months for the splenic artery aneurysms, rather than surgery or embolization, was suggested. There was no obvious interval change until now for 5 years. Transcatheter embolization or surgery will be considered if size progression or acute symptom developed.
Splenic artery aneurysm is a rare but life‐threatening condition. Up to 25% of splenic artery aneurysm will be complicated by rupture and the mortality rate after rupture is ranged from 25% and up to 70%, especially when the diameter is greater than 2 cm. 3 , 4 The patients often present with acute onset of hypovolemia shock and acute abdomen secondary to intra‐abdominal hemorrhage after rupture. Therefore, early diagnosis is crucial and whether surgery or transcatheter embolization will be needed for life‐saving. In most cases, splenic artery aneurysm was accidentally discovered by cross imaging. However, in our case report, the splenic artery aneurysm was exhibited as a SEL under EGD and near anechoic appearance under EUS. According to ASGE guideline, the differential diagnosis of anechoic lesion under EUS for gastric SEL includes lymphangioma, varices, and duplication cyst. 5 Although it was not mentioned by American Society for Gastrointestinal Endoscopy (ASGE) guideline, we need to take splenic artery aneurysm into the consideration when identifying a gastric SEL under EGD and anechoic lesion under EUS for early and appropriate diagnosis.
CONFLICT OF INTEREST
All authors declare no conflict of interest.
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