A challenging case of epigastric pain: diagnosis and mini-invasive treatment of a large gastroduodenal artery pseudoaneurysm

Abstract

The authors present a case of a gastroduodenal artery pseudoaneurysm in a patient with a medical history of pancreatic surgery. The lesion was found and evaluated by ultrasound, CT-angiography and then treated with trans-catheter embolisation. This mini-invasive approach led to a complete resolution of the lesion.

Background

Pseudoaneurysms of the gastroduodenal artery are rare and often late complications of pancreatic head resection; in addition, their incidence is probably under-reported in the literature.¹ They are serious because they may be difficult to diagnose and because they may become a life-threatening condition if not correctly treated.²

This case highlights the importance of the management of peri-pancreatic fluid collections in order to control the potential formation of pseudoaneurysms.

Case presentation

A 61-year-old male patient was admitted, at the end of November 2010, to the hospital for a mild epigastric pain that was lasting 2 days. His medical history included a major pancreatic surgery (intermediate resection of pancreas and pancreatic-gastrostomy) for a carcinoid of the anterior margin of the pancreas head in April 2010. The early postoperative period was unremarkable, and lab tests of the fluid drained through the two abdominal drains, positioned during the operation, were negative for pancreatic amylase.

His medical records were then reviewed and showed that, after 3–4 weeks from the surgical procedure, the patient developed infection symptoms (fever and leukocytosis).

The CT scan, done in May 2010, showed a small (3 cm thick) fluid collection at the pancreatic-gastric anastomosis that was treated with antibiotics.

Although a CT-guided drainage of the peri-pancreatic fluid collection was technically possible, the decision to opt for medical therapy instead of the interventional approach was, at that time, taken after a multi-disciplinary evaluation of both the bad clinical conditions of the patient and the risks of the percutaneous procedure.

Antibiotic therapy was started and it succeeded in solving the acute infection symptoms in 2 weeks. The patient was followed up with abdominal contrast-enhanced CT scans once a week in order to document the eventual enlargement of the peri-pancreatic collection and to evaluate the effect of the antibiotic therapy.

After 1 week from the resolution of the infection symptoms, the contrast-enhanced CT scan of the abdomen showed a reduction of the peri-pancreatic collection to a diameter of 15 mm that was considered non-drainable. Therefore, the patient was dismissed from the hospital and was followed up with scheduled abdominal CT-scans after 1 and 3 months from the hospital discharge.

Last contrast-enhanced CT scan (September 2010) did not demonstrate any enlargement of the pancreatic collection or other lesions.

On admission, the patient had constant upper abdominal pain, six out of ten in its intensity, and fatigue. He was afebrile and haemodynamically stable; moreover, physical examination showed only epigastric tenderness.

Blood tests revealed anaemia (haemoglobin concentration of 10.2 g/l) and a raised C reactive protein level of 15 mg/l (normal range <10 mg/l).

The ultrasound examination of the abdomen showed a nodular formation posteriorly to the stomach with an arterial Doppler signal (figure 1A).

Figure 1.

(A) US with arterial Doppler signal (black arrow) and (B) axial CT scan of the large gastroduodenal pseudoaneurysm (black arrowhead) surrounded by a peripancreatic fluid collection (white arrow).

The contrast-enhanced CT scan documented the presence of a peri-pancreatic fluid collection and a large (4 cm) pseudoaneurysm of the gastroduodenal artery figures 1B and 2A,B).

Figure 2.

(A) Coronal MPR and (B) VR CT-reconstructions of the large pseudoaneurysm (black arrow) and its vessels (gastroduodenal artery and inferior pancreatico-duodenal artery) (white arrow and arrowhead).

Investigations

The final diagnosis was possible with an abdominal ultrasound and a contrast enhanced CT scan (figure 1A,B).

Differential diagnosis

Differential diagnosis was with the main causes of epigastric pain and, in this particular patient, with a case of acute pancreatitis.

Treatment

Considering patient conditions and the invasiveness of an ‘open’ surgery, the chosen approach was endovascular.

The pseudoaneurysm was successfully treated using selective embolisation of the gastroduodenal artery and the inferior pancreatico-duodenal artery.

Through a right femoral artery percutaneous access, using a 4-French Cobra 2 catheter, a selective catheterisation of the gastroduodenal artery was achieved. The diagnostic angiography showed the large pseudoaneurysm of the gastroduodenal artery (figure 3A). First, the gastroduodenal artery was embolised with two 4 mm×5 cm coils, subsequently, the inferior pancreatico-duodenal artery, through the superior mesenteric artery, was embolised with two 3 mm×5 cm coils (figure 3B).

Figure 3.

AP view of the endovascular coil-embolisation of the gastroduodenal artery and the inferior pancretico-duodenal artery and axial CT of the postembolisation results the day after the interventional procedure: (A) selective angiography through the gastroduodenal artery that shows the pseudoaneurysm (white arrow); (B) angiogram after coil-embolisation of the gastroduodenal artery (arrowhead); (C) angiogram after coil-embolisation of the inferior pancreatico-duodenal artery, through the superior mesenteric artery (black arrow). (D) Axial CT scan done the day after the interventional procedure that led to a complete exclusion of the pseudoaneurysm.

A final angiogram demonstrated the complete exclusion of the pseudoaneurysm (figure 3C).

Outcome and follow-up

Follow-up included a contrast-enhanced CT scan the day after the treatment (figure 3D) and then after 1,3, 6 and 12 months. The day after the endovascular treatment, the pseudoaneurysm was completely excluded from the arterial blood flow and, soon after, the symptoms disappeared. Next contrast-enhanced CT scan is planned for August 2012.

Discussion

The formation of arterial pseudoaneurysms that develop in association with a pancreatic disease is due to the erosive action of pancreatic enzymes, such as elastase, on the walls of the adjacent blood vessels. This is a known complication of pancreatitis, with a incidence of 5%–10%^{3 4} but it has been uncommonly seen after a pancreatic surgical procedure,⁵ posing frequently a diagnostic and therapeutic dilemma.

The purpose of this article is to emphasise the fact that all percutaneously accessible peri-pancreatic fluid collections should be managed with a drainage (either CT or US-guided or endoscopy-guided).

Our case is an example of the effect of a subtle, non-drainable, fluid collection that was treated with only a medical approach that resulted in an initial clinical response.

Epigastric pain should be a key symptom in those patients with a positive history of pancreatic disease; sometimes other signs may be present such as jaundice and gastrointestinal bleeding that can be also of low volume and difficult to detect.

Conservative management of pseudoaneurysms is burdened by a death rate of more than 90%^{6 7}; therefore a correct diagnosis and treatment is virtually always necessary.

Some authors have reported a wide range of mortality after surgical treatment of such lesions (from 12.5% to 40%),⁸ moreover, the re-bleeding rate can occur in 6%–10% of patients who survive initial surgery.⁹

In conclusion, the interventional approach is rapidly becoming the primary therapeutic modality of pseudoaneurysms of the visceral arteries and many reports have showed a high efficacy^10–12 with a low rate of complications.

Learning points.

• ▶It is important to consider the drainage of those peri-pancreatic fluid collections that are percutaneously accessible in order to avoid the formation of visceral pseudoaneurysms.
• ▶Small non-drainable pancreatic bed collections, following pancreatic resection, should always be monitored with interval abdominal CT.
• ▶An accurate and complete diagnostic evaluation of the lesion and its collateral vessels is mandatory for the planning of a successful endovascular treatment.
• ▶Transarterial catheter embolisation is a technique that should be considered in the management of gastroduodenal pseudoaneurysms as it has a lower risk of complications and it is more cost-effective than traditional surgery.