CASE 10320 Published on 16.08.2012

Rare cause of gastrointestinal bleeding: hepatic artery aneurysm

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Luís Brito de Azevedo, Pedro Cordeiro, Rosa Cruz

Hospital Divino Espírito Santo
Av. Dom Manuel 9500-370 Ponta Delgada, Portugal
+351296 203 000

Email:luisbritoazevedogomes@net.sapo.pt
Patient

81 years, male

Categories
Area of Interest Vascular ; Imaging Technique CT, Catheter arteriography, Ultrasound
Clinical History
An 81-year-old male patient was admitted to the ER, referred from a health centre, with asthenia, nausea and haematemesis. Analytically a severe normocytic, normochromic anaemia (5.8 g/dL) stands out. Endoscopy was performed, showing active ulcer on the upper surface of the bulb with 10mm (Forrest IIC) and gastric antral ulcer with 10 mm (Forrest III).
Imaging Findings
Abdominal ultrasound was carried out, demonstrating an aneurysm with parietal eccentric thrombus, apparently originating in the hepatic artery (Fig. 1).

CT was performed, defining an aneurysm in the dependence of the hepatic/gastroduodenal artery, with 17x11cm, conditioning marked mass effect on the gastric antrum (Fig. 2).

Angiography is conducted for surgical mapping, although it was not possible to make selective catheterisation.

Surgery revealed a saccular aneurysm of the common hepatic artery and contiguous with the pylorus. Closure of the arterio-digestive fistula (Weinberg pyloroplasty), endoaneurysmorrhaphy and cholecystectomy, were performed (Fig. 3).

Patient was discharged a few weeks later and remained asymptomatic to date.
Discussion
The first description of a hepatic artery aneurysm (HAA) was published in 1809. Aneurysms of the hepatic artery represent approximately 20% of all arterial visceral aneurysms, and 80% of these, aneurysms of the extrahepatic segment [1, 2].

Its increasing incidence may be explained by the percutaneous invasive procedures that may cause damage to arterial walls. In the past, infection (mycotic aneurysms) was the main cause of hepatic aneurysms, and it is now a rarity. Presently the hepatic artery aneurysms undergo a process of medial degeneration, with subsequent atherosclerosis. A less common cause is polyarteritis nodosa and other vasculites, fibromuscular dysplasia, trauma, inflammation in the context of acute pancreatitis or cholecystitis, and as a postoperative complication of orthopic liver transplantation [1].

The form of presentation of HAA varies between an insidious onset and an accidental finding, or an acute haemorrhage after rupture, usually into the peritoneal cavity of the extrahepatic segment, or biliary tree with haemobilia if the intrahepatic segment is envolved. Upper/low gastrointestinal bleeding or signs of an acute abdomen, are common forms of presentation, as in the clinical case presented here.
In 65% of patients with HAA, rupture is the initial presentation. Contrary to the aortic aneurysm, there is no established relationship between the diameter and the risk of aneurysm rupture [1, 2].

Vascular calcification in plain radiograph or extrinsic compression on barium studies of the digestive organs may suggest the presence of aneurysm. Ultrasound and CT are the choice techniques, although the definition of the envolved artery is not always clear.
Angiography remains the method of choice for vascular study and pre-treatment either surgical or endovascular [1].

The treatment of choice is dependent on the location of the aneurysm. The common hepatic artery can be addressed both surgically and by embolisation. Intrahepatic aneurysm embolisation is accepted as the gold-standart modality [1, 3].
Differential Diagnosis List
Gastrointestinal bleeding by hepatic artery aneurysm.
Pseudo-aneurysm
Another origin of the aneurysm
Other causes of gastrointestinal bleeding
Final Diagnosis
Gastrointestinal bleeding by hepatic artery aneurysm.
Case information
URL: https://www.eurorad.org/case/10320
DOI: 10.1594/EURORAD/CASE.10320
ISSN: 1563-4086