CASE 10271 Published on 12.01.2013
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An uncommon cause of digestive bleeding: diagnostic approach and interventional treatment

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Matteoli Marco, Tesei Jacopo, Rossi Michele, David Vincenzo

Sant'Andrea Hospital,II Faculty of medicine "La Sapienza,Radiology; via di grottarossa 1035 Roma, Italy; Email:marcomatteoli@email.it
Connected authors
Patient

45 years, male

Categories
Area of Interest Abdomen ; Imaging Technique Fluoroscopy, CT, CT-Angiography
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Clinical History
A 45-year-old male patient presented with a sudden onset of epigastric pain and progressive asthenia. He was quite pale, tachycardic (HF 126 bpm), normocitic and normochromic anemia (Hb 7g/dl, MCV 80fl), serum amylase 180 IU/l. Alcohol intake 5-6U/day for 20 years. Smoker (30PY). A digital rectal examination revealed melena.
Imaging Findings
A digestive endoscopy showed a neoformation of the posterior gastric wall (Fig. 1), with a focal and bleeding corrosion in the central region.
A 16-Row MDCT imaging of abdomen showed a pseudo-nodular injury (43 x 28mm) at the pancreatic tail, with a mild compression against the lesser gastric curvature, and a slightly hyperdense appearance at basal images, with slow filling after administration of contrast medium, most evident in the venous phase (Fig. 2a-b).
The slight inhomogeneity of pancreatic tail and irregular appearance of the duct of Wirsung gave evidence for chronic pancreatitis (Fig. 2c). Digestive haemorrhage was secondary to corrosion of the gastric wall by a pancreatic pseudocyst, fistuled with a pseudoaneurysm of an unspecified peripancreatic vessel. A superselective angiogram of left gastric artery showed the position of the pseudoaneurysm and signs of active bleeding (Fig. 3). Embolization procedure was performed by an injection of spongostan at his afference (Fig3c).
Discussion
Major haemorrhages are a rare but lethal complication of pancreatitis, usually due to a rupture of pseudoaneurysms of a peripancreatic artery [1, 9]. Splenic, gastroduodenal and pancreaticoduodenal arteries are the commonly involved vessels. Left gastric artery is the less common [2].
To define the peripancreatic vessel, and to treat the pseudoaneurysm [3], an angiographic imaging and treatment were performed (Fig. 3), that in the haemodynamically stable patient, is a procedure that gives the best results in 67-100% of the cases [4-5].

The CT examination after embolization showed no evidence of the hyperdensity within the collection situated at the pancreatic tail, as a correct outcome of the procedure (Fig. 4a-b). Angiography is the gold standard to reveal pseudoaneurysms, however, CT examination is the best method to identify this atypical location [6] and the presence of pseudocysts, a localized collection of pancreatic fluid surrounded by granulation tissue and collagen [7], with a morphology of a located fluid collection with a peripheral enhancement (Fig 4a-b) [4].
Althought the embolization procedure of the neck preserves the flow along the artery, the risk of laceration secondary the infusion of embolisation material inside the aneurysm is very high [8]. In this case, spongostan was used as a closure device for the aneurysm, putting it only at the proximal region, because the distal zone was not available, and this kind of matherial was chosen to reduce the risks of ischaemia of the medial portion of the stomach, due to a complete obliteration of the left gastric artery. This approach provides the possibility to let the aneurysm coagulate and to resolve the bleeding, sparing the flow of the left gastric artery.
Differential Diagnosis List
Pancreatic pseudocyst, fistuled with a pseudoaneurysm of a ramus of left gastric artery.
Pseudoaneurysm
Gastric cancer
Pancreatic cancer
Final Diagnosis
Pancreatic pseudocyst, fistuled with a pseudoaneurysm of a ramus of left gastric artery.
Case information
URL: https://www.eurorad.org/case/10271
DOI: 10.1594/EURORAD/CASE.10271
ISSN: 1563-4086
Figure 1

16RowMDCT evaluation in arterial and venous phase

16RowMDCT evaluation in arterial and venous phase
A pseudo-nodular injury at the tail of the pancreas, after administration of intravenous contrast medium a slow filling in the lesion was seen, arterial phase shows the normal caliper of peripancreatic vessels.
16RowMDCT evaluation in arterial and venous phase
A pseudo-nodular injury at the tail of the pancreas, after administration of intravenous contrast medium filling of the active lesion was seen, most evident in the venous phase.
16RowMDCT evaluation in arterial and venous phase
Slight inhomogeneity of adipose tissue in the pancreatic tail, an irregular appearance of the duct of Wirsung, (black arrow), and intrapancreatic calcification (white arrow), was the CT diagnostic criteria for chronic pancreatitis.
Figure 2

Digestive endoscopy findings

Digestive endoscopy findings
A neo formation jutting out the lumen, and covered with hyperplastic mammillated mucosal, with a bleeding focal corrosion in the central region.
Figure 3

Angiogram of left gastric artery

Angiogram of left gastric artery
The angiogram of the left gastric artery showed a contrast blush suggestive of active bleeding.
Angiogram of left gastric artery
The angiogram of the left gastric artery showed a contrast blush suggestive of active bleeding.
Angiogram of left gastric artery
A super-selective angiogram of the left gastric artery at the emerging of the pseudo-aneurysm failed, due to arterial spasm, so the embolisation strategy was to close the artery proximately with spongostan.
Figure 4

Embolization evaluated with CT examination

Embolization evaluated with CT examination
The CT performed after the embolisation showed no evidence of arterial hyperdensity within the collection situated among the little curve of the stomach a the pancreatic tail.
Embolization evaluated with CT examination
The CT performed after the embolisation showed no evidence of venous hyperdensity within the collection situated among the little curve of the stomach a the pancreatic tail.