1. PATIENT PRESENTATION
A 65‐year‐old man with a history of hepatocellular carcinoma presented to our emergency department with hematochezia and gross hematuria for 1 day. On arrival, he was tachycardic and normotensive, his temperature was 36.4°C (97.5°F), his pulse rate was 121, and his blood pressure was 106/78 mm Hg. The abdominal examination result was unremarkable. He denied taking any antiplatelet and anticoagulation medication. He had a white blood count of 16,000/mL, Hb of 10.4 g/dL, platelet count of 298,000/μL, international normalized ratio of 1.06, and a C‐reactive protein level of 5.71 mg/dL. He was appropriately resuscitated. Hematuria was improved after irrigation with a Foley catheter, while a 50‐cc blood clot and wall thickening of the right lateral urinary bladder were recorded by a genitourinary specialist. Subsequently, he underwent colonoscopy, and the retention of a very large blood clot in the A‐colon was observed, without obvious active bleeding. Through the above evaluation, no definite bleeding lesion was identified, but hematochezia persisted. His Hb dropped from 10.4 to 6.3 g/dL within 24 hours, although tranexamic acid, pantoprazole, and somatostatin were prescribed. A massive transfusion protocol (red blood count, 6 U; fresh frozen plasma, 2 U; and platelet pheresis, 1 U) was initiated, and emergency computed tomography angiography was performed (Figure 1).
FIGURE 1.
CTA (Computed tomography angiography) protocol showing (A) a pseudoaneurysm of ≈3.2 × 2.7 cm in the right external iliac artery (EIA). (B) Coronal plane of the same patient revealing inflammatory changes of the right psoas muscle, urinary bladder, and nearby terminal ileum (arrows)
2. DIAGNOSIS
2.1. Right external iliac artery pseudoaneurysm with arteriocolic fistula
Iliac artery pseudoaneurysm is a rare but lethal cause of gastrointestinal and genitourinary hemorrhage. 1 , 2 , 3 These patients often undergo multiple endoscopic workups, but no conclusive findings are reported, corresponding to a diagnostic challenge and delays of time‐sensitive, definite endovascular or operative treatment. Therefore, for patients with gastrointestinal bleeding and risk factors, such as a history of prior vascular intervention, trauma, benign or malignant tumors, inflammation or infection, and atherosclerosis, arterioenteric or arteriocolic fistula must be suspected. 4 Adequate resuscitation, prompt diagnosis, and immediate proper treatment can be lifesaving.
The patient underwent angiography, and a stent graft was inserted in the right external iliac artery (Figure 2). Hematochezia was successfully stopped, and the patient's hemodynamic status stabilized. He was started on oral diet 3 days later, and no further hematochezia was observed during hospital admission.
FIGURE 2.
Angiography showing (A) a pseudoaneurysm of the right external iliac artery (EIA) (arrow) and (B) the follow‐up arteriogram after the deployment of a 7 mm × 50 mm stent graft (arrowhead)
Chang H‐M, Lin P‐Y. Middle‐aged man presenting with hematochezia and hematuria. JACEP Open. 2021;2:e12584. 10.1002/emp2.12584
REFERENCES
- 1. Policha A, Baldwin M, Mussa F, Rockman C. Iliac artery‐uretero‐colonic fistula presenting as severe gastrointestinal hemorrhage and hematuria: a case report and review of the literature. Ann Vasc Surg. 2015;29:1656. e1‐e6. [DOI] [PubMed] [Google Scholar]
- 2. McFarlane MEC, Plummer J, Simpson L, et al. Internal iliac artery aneurysmo‐colonic fistula: a rare presentation of massive lower gastrointestinal haemorrhage: report of a case. Eur Surg. 2009;41:129‐131. [Google Scholar]
- 3. Kurata S, Tobu S, Udo K, Noguchi M. Iliac artery‐uretero‐colonic fistula presenting as gastrointestinal hemorrhage and hematuria: a case report. J Endourol Case Rep. 2018;4:1‐4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Sueyoshi E, Sakamoto I, Nakashima K, Minami K, Hayashi K. Visceral and peripheral arterial pseudoaneurysms. AJR Am J Roentgenol. 2005;185:741‐749. [DOI] [PubMed] [Google Scholar]