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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 33-35

Spontaneous rupture of splenic artery pseudoaneurysm into walled-off pancreatic necrosis – A rare cause of recurrent hematochezia


1 Department of Gastroenterology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
2 Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Submission27-Aug-2021
Date of Decision04-Oct-2021
Date of Acceptance08-Nov-2021
Date of Web Publication01-Jan-2022

Correspondence Address:
Rajeeb Jaleel
Department of Gastroenterology, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_38_21

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  Abstract 


Splenic artery pseudoaneurysm rupturing into walled-off pancreatic necrosis and manifesting as hematochezia is very uncommon. We report one such unusual presentation. A 36-year-old man presented with recurrent episodes of hematochezia requiring multiple blood transfusions in 2 months. Upper and lower gastrointestinal endoscopy ruled out any source of the bleed. CT angiography revealed pseudoaneurysm from the splenic artery leading onto a walled-off pancreatic necrotic collection; the collection had fistulous communication to the colon. The aneurysm was coil embolized and he was discharged in a clinically stable state.

Keywords: Embolization, hematochezia, splenic artery pseudoaneurysm, walled-off pancreatic necrosis


How to cite this article:
Sairam P S, Jaleel R, Dutta AK, Padmanabhan A. Spontaneous rupture of splenic artery pseudoaneurysm into walled-off pancreatic necrosis – A rare cause of recurrent hematochezia. Gastroenterol Hepatol Endosc Pract 2022;2:33-5

How to cite this URL:
Sairam P S, Jaleel R, Dutta AK, Padmanabhan A. Spontaneous rupture of splenic artery pseudoaneurysm into walled-off pancreatic necrosis – A rare cause of recurrent hematochezia. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Sep 30];2:33-5. Available from: http://www.ghepjournal.com/text.asp?2022/2/1/33/334700




  Introduction Top


Acute lower gastrointestinal (GI) bleeding has an annual incidence of hospitalization of approximately 36/100,000 population.[1]

Colonic causes include diverticulosis, vascular ectasia, colitis (ischemia, infectious, inflammatory bowel disease, and radiation proctopathy), neoplasia, postpolypectomy bleeding, and anorectal causes (hemorrhoids and rectal varices). Extracolonic causes include infiltration by malignancies or rupture of adjacent structures or systemic causes (coagulopathy).

Spontaneous rupture of splenic artery pseudoaneurysm into walled-off pancreatic necrosis (WOPN) presenting as hematochezia is very uncommon and has rarely been reported. We present one such case.


  Case Report Top


A 36-year-old man with a history of significant ethanol consumption presented with recurrent episodes of passing fresh blood in the stools in 2 months. He was managed conservatively in a nearby hospital and was transfused 12 units of blood in total in 2 months. There was no hematemesis, melena, fever, jaundice, abdominal pain, or distension. He remained asymptomatic between the episodes. He presented to our hospital during the current episode.

Past medical history includes intermittent episodes of epigastric pain for 5 years. His last pain episode was 1 year back. There was no history of any comorbidity, surgery, or trauma.

He was hemodynamically stable at presentation. There was pallor; his abdomen was soft. Digital rectal examination showed fresh blood. Clinical examination was otherwise unremarkable.

His hemoglobin was 6.8 g% on admission. Investigations were otherwise normal. Upper GI endoscopic evaluation was normal. Colonoscopy that was done earlier was also normal.

Computed tomography (CT) angiogram showed features of chronic calcific pancreatitis with walled-off necrotic collection. It revealed splenic artery pseudoaneurysm as focal outpouching [Figure 1] leading onto the necrotic collection [Figure 2] and fistulous communication between the collection and splenic flexure of the colon [Figure 3]. Chronic splenic vein thrombosis with collaterals and multifocal splenic infarcts were also seen.
Figure 1: Computed tomography angiogram (on the left) and three-dimensional reconstruction computed tomography angiogram (on the right) showing dilated and tortuous splenic artery with arrows pointing at the inferiorly directed focal outpouching (focal splenic artery pseudoaneurysm)

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Figure 2: Pseudoaneurysm of the splenic artery (shown by solid arrow) leading into the walled-off pancreatic necrotic collection (shown by dashed arrow)

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Figure 3: Contrast-enhanced computed tomography of the abdomen coronal section showing walled-off necrotic collection fistulizing into the splenic flexure of colon; arrow pointing at the fistulous communication

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The source of hematochezia was considered to be the splenic artery pseudoaneurysm that was bleeding into walled-off necrotic collection which had fistulous communication to splenic flexure of colon with underlying ethanol-related chronic pancreatitis.

The patient was managed with blood transfusion, intravenous fluids, and pantoprazole.

He was taken up for splenic artery coil embolization. Under local anesthesia, right common femoral artery access was obtained and 5F sheath was placed. The splenic artery was catheterized, and angiogram revealed pseudoaneurysm arising from the distal splenic artery. The pseudoaneurysm was trapped and embolized using three pushable coils distally and four pushable coils proximally. Postprocedural angiogram showed no filling of aneurysm sac or active bleeding [Figure 4].
Figure 4: Angiogram of the splenic artery showing pseudoaneurysm after successful coil embolization

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There was no further overt bleed or hemoglobin drop. He was advised strict alcohol abstinence, fat-free diet, hematinics, and discharged in a stable state. His hemoglobin improved to 11.4 g% during his follow-up outpatient department visit after 6 weeks.


  Discussion Top


Splenic artery is defined as aneurysmal when focal dilation of >50% is present. True aneurysms involve all layers of the vessel wall, each of which is intact and thinning. Pseudoaneurysms are due to tear in vessel wall intima with subsequent blood dissection into false lumen and periarterial hematoma formation.[2] Splenic artery is the most common visceral artery known to form pseudoaneurysm. Unlike true aneurysms, splenic artery pseudoaneurysms nearly always present with symptoms.

Clinical features include abdominal pain (29.5%), melena (26.2%), hemosuccus pancreaticus, (20.3%), and hematemesis (14.8%).[3] The risk of rupture of a splenic artery pseudoaneurysm can be as high as 37%, with the mortality rate approaching 90% when untreated.[4],[5]

Pancreatitis, in both acute and chronic forms, is the most common cause of splenic artery pseudoaneurysms.[3] Other causes include blunt abdominal trauma, peptic ulcer disease, and iatrogenic injury to the splenic artery.

Due to its contiguity with pancreas, splenic artery is the most common artery involved, followed by gastroduodenal, pancreaticoduodenal, hepatic, and left gastric arteries.[6]

Direct or indirect (intracystic) rupture of pseudoaneurysm may take place into GI tract, peritoneal cavity, retroperitoneum, or pancreatic duct, of which GI tract is the most frequent location.[7]

Pseudoaneurysm formation occurs through pancreatic enzymatic autodigestion of splenic arterial wall, causing fragmentation of elastic tissue and weakening of vessel wall architecture resulting in necrotizing arteritis.[8]

WOPN is a late complication of acute pancreatitis, although it can occur in chronic pancreatitis.[9] Long-standing pancreatic collection may induce pseudoaneurysm formation by vascular erosion from enzymes within the collection, direct compression, or ischemia.

Multislice CT angiography is considered the imaging modality of choice for GI bleeding. It helps to evaluate vascular arcades and localize the bleeding site. Direct catheter angiography is the gold standard imaging modality for small vessels and is part of endovascular treatment.

Our patient presented with intermittent lower GI bleed that required multiple transfusions. Since endoscopic evaluation was unyielding, CT angiography was done which revealed a small splenic artery pseudoaneurysm. All splenic artery pseudoaneurysms should be repaired, regardless of size or symptoms, as the timing of rupture is unpredictable.[3]

Transcatheter arterial embolization is the current intervention of choice. Endovascular techniques using coils, detachable balloons, inert particles, or Gelfoam (gelatin sponge) have reported success rates of 75%–85%.[10]

Surgical options include splenectomy with or without distal pancreatectomy, ligation of splenic artery with resection of pseudoaneurysm, and transcystic ligation of bleeding vessel with internal and external pseudocyst drainage. Other treatment options include percutaneous injection of thrombin into pseudoaneurysmal sac.

Our patient underwent radiological intervention with coil embolization of splenic artery pseudoaneurysm. Proximal blockade alone would not suffice, as the vascular bed is highly collateralized from surrounding arteries. Embolization of normal portions of the artery, both distal and proximal to pseudoaneurysm with coils, is considered the best endovascular procedure as it excludes the aneurysm from circulation and enables thrombosis. Hence, we carried out the same for our patient and he showed good response.

Interesting features in our case include the absence of symptoms of pancreatitis in the past 1 year, pseudoaneurysm rupturing into WOPN and manifesting as hematochezia. This presentation has rarely been reported.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgments

  • Dr Shalini Sahu, Resident, Department of Radiodiagnosis, who was involved in the reporting of the CT angiogram
  • Dr Shyamkumar N Keshava, Professor and Head, Department of Interventional Radiology, Christian Medical College Hospital, Vellore, who was involved in the clinical decision-making and management.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ghassemi KA, Jensen DM. Lower GI bleeding: Epidemiology and management. Curr Gastroenterol Rep 2013;15:333.  Back to cited text no. 1
    
2.
Kassem MM, Gonzalez L. Splenic Artery Aneurysm. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430849/. [Last accessed on 2021 Jul 21].  Back to cited text no. 2
    
3.
Tessier DJ, Stone WM, Fowl RJ, Abbas MA, Andrews JC, Bower TC, et al. Clinical features and management of splenic artery pseudoaneurysm: Case series and cumulative review of literature. J Vasc Surg 2003;38:969-74.  Back to cited text no. 3
    
4.
LiPuma JP, Sachs PB, Sands MJ, Stuhlmiller S, Herbener TE. Angiography/interventional case of the day. Splenic artery pseudoaneurysm associated with pancreatitis. AJR Am J Roentgenol 1997;169:259, 262-3.  Back to cited text no. 4
    
5.
Huang IH, Zuckerman DA, Matthews JB. Occlusion of a giant splenic artery pseudoaneurysm with percutaneous thrombin-collagen injection. J Vasc Surg 2004;40:574-7.  Back to cited text no. 5
    
6.
Mallick IH, Winslet MC. Vascular complications of pancreatitis. JOP 2004;5:328-37.  Back to cited text no. 6
    
7.
Zhao J, Kong X, Cao D, Jiang L. Hematochezia from splenic arterial pseudoaneurysm ruptured into pancreatic pseudocyst coexisting with fistula to the colon: A case report and literature review. Gastroenterology Res 2014;7:73-7.  Back to cited text no. 7
    
8.
Puri S, Nicholson AA, Breen DJ. Percutaneous thrombin injection for the treatment of a post-pancreatitis pseudoaneurysm. Eur Radiol 2003;13 Suppl 4:L79-82.  Back to cited text no. 8
    
9.
Elgendy A. Walled-Off Pancreatic Necrosis | Radiology Reference Article | Radiopaedia.Org. Radiopaedia. Available from: https://radiopaedia.org/articles/walled-off-pancreatic-necrosis-1. [Last accessed on 2021 Apr 19].  Back to cited text no. 9
    
10.
Guillon R, Garcier JM, Abergel A, Mofid R, Garcia V, Chahid T, et al. Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients. Cardiovasc Intervent Radiol 2003;26:256-60.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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