Clinical Case Summary

Splenic artery (SA) pseudoaneurysms are rare but potentially fatal complications of pancreatitis, with a mortality rate up to 52%. A good prognosis relies on early diagnosis and treatment.
A 54-year-old man, recently splenectomized due to spleen rupture, and with a history of alcohol and tobacco abuse presented with hematemesis, melena and acute anemia. Upper endoscopy revealed a blood vessel without ulcer in the posterior gastric body (PGB), suggestive of Dieulafoy lesion, treated with adrenaline and through-the-scope clips (TTSC). During hospitalization there were 2 more hemorrhagic events: the first treated with TTSC; the second with an over-the-scope clip (OTSC).
Weeks after being safely discharged, he presented with hematemesis, epigastric pain and acute anemia. A presumed Dieulafoy lesion in the PGB was treated with an OTSC. A computed tomography (CT) scan was performed to exclude vascular malformations, revealing an hipodense heterogeneous area in the pancreas tail contacting the SA and the PGB, suggestive of intraductal papillary mucinous neoplasm with malignant transformation.
An endoscopic ultrasound with biopsy was scheduled but, before that happened, another episode of hematemesis with hemodynamic instability required a CT scan, revealing a pseudocyst adjacent to the PGB. Reviewing his medical records from another hospital: a CT scan performed at the time of the spleen rupture described this collection, consistent with a pseudocyst based on cytology.
Subsequent angiography confirmed a SA pseudoaneurysm communicating with PGB, treated with microcoil embolization. The patient was discharged after an uneventful recovery. No more hemorrhagic events were recorded for 10 months.
SA pseudoaneurysms require a high index of suspicion for early diagnosis. This case emphasizes the importance of reviewing medical records and considering previous evidence of pancreatitis in at risk patients. Prompt diagnosis and intervention can prevent life-threatening hemorrhage.

References

Endoscopic images (a total of 10-12 pictures); CT scan images (a total of 3-4).

Clinical Case Summary

Introduction: Primary splenic angiosarcoma is a rare neoplasm of vascular origin with aggressive behavior, atypical clinical presentation and poor prognosis because of its high metastatic potential. This disease often presents with spontaneous rupture and lethal hemorrhage.^1-5
Case report: We report an 81-year-old woman who presented with a 1-month history of melena. The patient was hemodynamically stable and laboratory investigations showed a significant drop in hematocrit (Hct: 19.4%, Hb: 6,5 g/dL). The patient underwent upper GI endoscopy which revealed two hemorrhagic polypoid lesions, one in the greater curvature of the stomach and one in the second part of the duodenum (Figure A, B). Then, a polypectomy was performed for each lesion and specimens were sent for histological examination. Two weeks later, the patient experienced a recurrence of bleeding and a re-endoscopy was performed which revealed “regeneration” of the previously resected polypoid lesions. The bleeding gastric polyp had a visible vessel where an over-the-scope clip (OTSC) placement was successfully performed. After the gastrointestinal bleeding subsided in the next few days, the patient presented with acute abdominal pain and abdominal distension, with a dramatic drop in hematocrit and hemοdynamic instability. An urgent CT angiography was performed, showing (spontaneous) rupture of the spleen and hemoperitoneum (Figure C). Finally, the patient underwent splenectomy and from the histopathological evaluation of the surgical specimen and from the gastric and duodenal specimens she was diagnosed with primary splenic angiosarcoma with synchronous gastric and duodenal metastases.
Conclusions: Splenic angiosarcoma is a very rare malignancy and the majority of patients have metastases at the time of diagnosis. We recommend a high degree of vigilance in patients with multiple sites of gastrointestinal bleeding and early investigation of possible underlying disease.

References

1. Duan YF, Jiang Y, Wu CX, Zhu F. Spontaneous rupture of primary splenic angiosarcoma: a case report and literature review. World J Surg Oncol. 2013 Mar 4;11:53.
2. Bergas A, Escrihuela-Vidal F, Fernández Calvo D, Capdevila Pons O, Corbella X. Relapsing Haemothorax as an Unusual Presentation of Primary Angiosarcoma of the Spleen. Eur J Case Rep Intern Med. 2020 Oct 29;7(12):001944.
3. Maeyashiki C, Nagata N, Uemura N. Angiosarcoma involving solid organs and the gastrointestinal tract with life-threatening bleeding. Case Rep Gastroenterol. 2012 Sep;6(3):772-7.
4. Juin Hsien BL, Shelat VG. Spleen angiosarcoma: a world review. Expert Rev Gastroenterol Hepatol. 2021 Oct;15(10):1115-1141.
5. Fiorentino MD, Monteiro JMC, de Siqueira REB, Kim EIM, Curi AP, Ferrreira CR, Nardo M, de Campos FPF. Primary splenic angiosarcoma: a rare entity often associated with rupture and hemoperitoneum. Autops Case Rep. 2019 Jul 12;9(3):e2019100.

Clinical Case Summary

65-year-old female initially presented to the emergency room with upper gastrointestinal (GI) bleeding with melena. Initial endoscopy showed a 7cm submucosal partially obstructing tumor originating in the lower esophagus extending into the gastric cardia, biopsied and negative for malignancy. An EUS performed after showed that the mass was arising from deep mucosa (layer 2), FNA with no fluid which showed granulation tissue with active inflammation. Repeat EUS with FNB a month later showing 5.4 x 3.9 cm mass from layer 2 biopsies again negative for malignancy and only showed inflammatory fibrous lesion. Patient had 3 episodes of upper GI bleeding which self-resolved on two occasions and later treated with local therapy including hemostatic spray with control of bleeding from the ulcerated area of the lesion. Patient went on to develop dysphagia because of the obstructing lesion resulting in weight loss and a percutaneous gastrostomy tube was placed for nutrition supplementation. Patient initially was hesitant to have any definitive treatment as there was no concerns for an aggressive malignancy. 11 months since the diagnosis of the lesion, patient had a GI bleeding that didn’t stop despite endoscopic treatment and the patient finally had a partial gastrectomy with removal of pedunculated gastroesophageal junction mass and creation of vascularized omental pedicle flap. Pathology finally revealed a 497g, 16 x 9.5 x 4.5 cm soft tissue mass showing polypoid myxoid vascular spindle cell neoplasm with mucosal ulceration concerning for plexiform fibromyxoma (PF) with positive margins. Repeat endoscopy after 6 months showing no evidence of recurrence. Patient’s symptoms improved and was able to tolerate oral feeds without issue at 6 months.
PF is a rare entity under-recognized causing recurrent bleeding and is not known to cause any malignant transformation or metastasis. We present this case with difficulty with diagnosis and management requiring surgical resection

References

Arslan ME, Li H, Fu Z, Jennings TA, Lee H. Plexiform fibromyxoma: Review of rare mesenchymal gastric neoplasm and its differential diagnosis. World J Gastrointest Oncol. 2021 May 15;13(5):409-423. doi: 10.4251/wjgo.v13.i5.409. PMID: 34040702; PMCID: PMC8131905.

Clinical Case Summary

Introduction: Hepatic artery pseudoaneurysms are a low incidence (0.3–2.5%) but life-threatening complication. Fistulization of such pseudoaneusrysms into the gallbladder and duodenum is extremely rare and is an unusual cause of hemobilia.^1-7
Case report: A 54-year-old man, without history of traumatism, hepatobiliary surgery or intervention on the hepatobiliary tract, presented with Quincke’s triad of symptoms, upper gastro-intestinal hemorrhage (melena), jaundice and upper abdominal pain. The patient was haemodynamically unstable (BP: 86/49 mmHg, HR: 113/min), while the laboratory tests showed significant reduction in hematocrit (Hct: 25,4%, Hb: 8,3 g/dL), elevated markers of inflammation (WBCs: 20.500/μL, CRP: 25 mg/dL) and abnormal liver function tests (TBL: 3,9 mg/dL, DBL: 3 mg/dL, SGOT: 220 U/l, SGPT: 413 U/l, γGT: 497 U/l, ALP: 211 U/l). The patient was resuscitated and after stabilization he underwent upper GI endoscopy which showed an attached thrombus in the second part of the duodenum, with a pulsating duodenal wall (Figure A). Thrombus detachment revealed an external orifice of a fistula. A vascular lesion was then suspected and an urgent CT scan was performed. The CT scan confirmed the presence of a common hepatic artery pseudoaneurysm, 2.5cm in diameter, localized in the region of the gallbladder fossa, complicated with cholecystoduodenal fistula due to eroding cholecystitis (Figure B). Arterial catheterization and angiographic evaluation of the common hepatic artery pseudoaneurysm was performed, followed by a fully covered stent placement (Figure C). The postoperative course was uneventful and the patient was discharged on the 10^th postoperative day.
Conclusions: Pseudoaneurysm of the common hepatic artery is rare but potentially fatal. In the literature, there is no other case o hemobilia originating from a common hepatic artery pseudoaneurysm with cholecystoduodenal fistula due to eroding cholecystitis.

References

1. Landolsi S, Landolsi M, Mannai S. Spontaneous right hepatic artery branch gallbladder fistula revealed by haemobilia and upper cataclysmic gastrointestinal bleeding. BMJ Case Rep. 2018 Jan 3;2018:bcr2017222134.
2. Totolici BD, NeamŢu C, Bodog FD, Bungău SG, Goldiş DS, Matei M, Andercou OA, Amza OL, Gyori Z, Coldea L. Hemobilia by idiopathic aneurysm of cystic artery, fistulized in the biliary ways - clinical case. Rom J Morphol Embryol. 2017;58(1):267-270.
3. Das M, Volmar FH, Walayat S, Nolte R. Hemobilia from a right hepatic artery pseudoaneurysm due to chronic cholecystitis. SAGE Open Med Case Rep. 2019 Aug 23;7:2050313X19872075.
4. Sawalha K, Kunnumpurath A, McCann R. An Unusual Cause of an Intraperitoneal Bleed: Bleeding Hepatic Artery Pseudoaneurysm Due to an Eroding Cholecystitis. J Investig Med High Impact Case Rep. 2020 Jan-Dec;8:2324709620982431.
5. Shelton J, Raviraj S. A Case Report: Hepatic artery pseudoaneurysm causing life-threatening haemobilia. Int J Surg Case Rep. 2021 Sep;86:106350.
6. Traa AC, Hoven-Gondrie ML, Diederik AL. A pseudoaneurysm of the right hepatic artery treated successfully with a stent graft - A case report. Int J Surg Case Rep. 2020;77:407-411.

Clinical Case Summary

Introduction: Pancreatitis is an inflammatory disorder of the pancreas resulting in various complications, such as parenchyma/peripancreatic fluid collections and necrosis pseudocyst formation, benign biliary stricture and vascular complications like venous thrombosis and pseudoaneurysmal bleeding.
Case report: A 48-year-old man with a history of chronic alcohol consumption presented with abdominal pain and melena. He had no history of traumatism, hepatobiliary surgery or intervention on the hepatobiliary tract, but suffered from recurrent pancreatitis. The patient manifested Quincke’s triad of symptoms, upper gastro-intestinal hemorrhage (melena), jaundice and upper abdominal pain, without a pulsatile mass. The patient was haemodynamically stable with positive digital rectal exam for blood, while the laboratory tests showed significant reduction in hematocrit (Hct: 23,6%, Hb: 7,7 g/dL), elevated serum amylase (AMY: 780 U/l) and hyperbilirubinemia (TBL: 3 mg/dL, DBL: 2,3 mg/dL, γ-GT: 531 U/l, ALP: 443 U/l). The patient underwent upper GI endoscopy which showed an attached thrombus in the papilla of Vater (Figure A), with a pulsating duodenal wall. A vascular lesion was then suspected and an urgent contrast-enhanced computed tomography (CT) scan was performed. The CT scan confirmed the presence of a pancreaticoduodenal arterial pseudoaneurysm (Figure B, red arrow) due to an eroding pancreatic pseudocyst (Figure B, green arrow) filled with blood clots, without active extravasation. Ultimately, we decided to treat the patient using endovascular therapy. Arterial catheterization and angiographic evaluation of the pancreaticoduodenal pseudoaneurysm was performed, followed by coil embolization (Figure C). The postoperative course was uneventful and the patient was discharged on the 16^th postoperative day.
Conclusions: Bleeding pseudoaneurysm is a rare but life-threatening complication of pancreatitis with high rates of mortality if left untreated.

References

1. Barka, M., Rguez, A., Ben Cheikh, Y., Chaouch, M. A., Jarrar, M. S., Ben Abdessalem, Z., Hamila, F., & Youssef, S. A case report of gastroduodenal artery pseudoaneurysm and giant pancreatic pseudocyst following acute pancreatitis revealed by obstructive jaundice. SAGE Open Med Case Rep. 2023 Jul 29:11:2050313X231188885.
2. Walia, D., Saraya, A., & Gunjan, D. Vascular complications of chronic pancreatitis and its management. World J Gastrointest Surg. 2023 Aug 27;15(8):1574-1590.
3. Dhali, A., Ray, S., Sarkar, A., Khamrui, S., Das, S., Mandal, T. S., Biswas, D. N., & Dhali, G. K. Peripancreatic arterial pseudoaneurysm in the background of chronic pancreatitis: clinical profile, management, and outcome. Updates Surg. 2022 Aug;74(4):1367-1373.
4. Shelar SS, Dhande R, Nagendra V, Suryadevara M, Shetty N. Giant Abdominal Pseudoaneurysm Secondary to Recurrent Pancreatitis: Imaging and Endovascular Intervention. Cureus. 2022 Dec 23;14(12):e32872.
5. Chiang, H. C., Lo, Y. N., Chen, C. Y., Chuang, C. H., Hong, T. C., & Kuo, H. Y. Acute pancreatitis complicated with peripancreatic pseudoaneurysm and subsequent intra-abdominal hematoma. JGH Open. 2023 May 9;7(5):393-394.

Introduction

Upper gastrointestinal bleeding (UGIB) is a major cause of mortality in the United States (US). This study aimed to investigate the contemporary trends in the management and outcomes of these patients as well as factors associated with in-hospital mortality, using national data.

Aims & Methods

The US National Inpatient Sample was queried from 2016-2020. Using International Classification of Diseases 10th Revision Codes, all adults >18 admitted with a principal discharge diagnosis of UGIB were extracted along with data about demographics, management and outcomes. Categorical variables were compared using chi-squared and expressed as percentages (%). Logistic regression was performed, adjusting for variables associated with adverse outcomes and reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Data were considered significant if p<0.001.

Results

There were 918,925 hospitalizations for UGIB in the study period. Variceal bleeding occurred in 36,050 (3.9%) of admissions. Endoscopy was performed in 451,450 (49.1%) of admissions, with 10,160 (1.1%) of admissions and 9,355 (1.0%) of admissions requiring interventional radiology and gastrointestinal surgery to control blood loss respectively. The crude rate of all-cause in-hospital mortality was 1.9%. Factors associated with death included variceal bleed (aOR 2.84 CI 2.67-3.02), age (aOR 1.03 CI 1.03-1.03), history of cancer (aOR 2.45 CI 2.35-2.56), ulcer disease (aOR 1.44 CI 1.39-1.49), chronic renal failure (aOR 1.34 CI 1.29-1.37), chronic obstructive pulmonary disease (aOR 1.29 CI 1.24-1.34), receipt of endoscopy (aOR 1.33 CI 1.29-1.38), surgery (aOR 3.92 CI 3.63-4.24) and interventional radiology (aOR 3.33 CI 3.09-3.58).

Conclusion

UGIB remains a significant cause of hospitalisation in the US. Knowledge of the contemporary trends and outcomes of this patient group is important to improve management in this at-risk patient group.