Binita M. Kamath, MBBChir; Robin Kaye, MD; Petar Mamula, MD Series Editors: David A. Piccoli, MD; Petar Mamula, MD

Disclosures

December 28, 2004

Discussion

The differential diagnosis of upper gastrointestinal bleeding in a young child includes esophagitis, peptic ulcer disease, Mallory-Weiss tear, esophageal varices, intestinal webs, duplications, and vascular anomalies. In regard to this patient, the radiographic and endoscopic studies excluded most of these diagnoses. The upper endoscopy indicated that the source of bleeding was from the pancreatic duct.

Classically, hemosuccus pancreaticus occurs in the setting of chronic pancreatitis when inflammatory changes result in a visceral artery aneurysm, which subsequently ruptures into the pancreatic duct. Other causes of hemosuccus pancreaticus are rare; however, in this patient, there was no history of pancreatitis and no evidence of pancreatic disease.

A magnetic resonance angiogram was performed in which there was a collection of contrast, approximately 5 mm in diameter, located at the level of the duodenal bulb. Based on the clinical and radiologic findings, a visceral artery aneurysm was suspected. Therefore, an angiogram was performed and an aneurysm of the gastroduodenal artery was identified (Figure).

Angiogram showing gastroduodenal artery aneurysm (arrow).

Gastroduodenal artery aneurysms are an example of visceral aneurysms, which are the most infrequent aneurysms affecting the arterial circulation. Other visceral aneurysms include splenic, hepatic, and superior mesenteric artery aneurysms.

Splenic artery aneurysms occur most commonly, accounting for 60% of all visceral aneurysms. These aneurysms may arise as a complication of medial fibrodysplasia, multiparity, or portal hypertension. Hepatic artery aneurysms usually result from trauma and comprise 20% of visceral aneurysms. Finally, superior mesenteric artery aneurysms are usually infectious in etiology and are often seen in intravenous-drug users.

Gastroduodenal artery aneurysms account for less than 2% of visceral aneurysms. The male:female ratio of occurrence is 4:1, and the aneurysms commonly occur in individuals over 50 years of age. Most gastroduodenal artery aneurysms arise in the setting of pancreatitis. Aneurysm formation may be associated with pancreatitis-related vascular necrosis (periarterial inflammation) or vessel erosion by an adjacent pancreatic pseudocyst. Occasionally, gastroduodenal artery aneurysms may occur as an isolated finding, presumably congenital in origin, as in this case, or as a complication of a collagen vascular disorder, such as Ehlers-Danlos type IV.

Gastroduodenal artery aneurysms may present with gastrointestinal bleeding, as in the case presented here, or with abdominal pain, gastric outlet obstruction, obstructive jaundice, or as an incidental finding.

This patient was successfully treated with transcatheter coil embolization at the time of the angiography. In recent years, interventional radiologic procedures have superceded surgery in the management of these aneurysms. The patient did well after the procedure and has had no further bleeding episodes.

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