Kyle Fischer, MD, Melissa Jordan, MD, Wesam Frandah, MD
University of Kentucky College of Medicine, Lexington, KY
Introduction: Hepatic Artery Psuedoaneurysms (HAPs) are typically caused by iatrogenic injury from instrumentation during invasive procedures or trauma. Psuedoaneurysms are described as a disruption/tear through all three layers of the arterial wall, with a fibrous capsule intact. Detection of HAP is important, as the rupture rate is around 76%.
Case Description/Methods: A 77-year-old male with PMH of chronic pancreatitis with pseudocyst formation and necrotizing pancreatitis presented to the emergency department with 36 hours of black stools and diffuse abdominal pain. Admission labs showed a hemoglobin of 11.4 gm/dl, AST of 113 U/L, ALT 197 U/L, lipase 535 U/L. Given his past history and acute transaminitis, CT abdomen/pelvis was completed and showed 1.7 x 1.5 cm pseudoaneurysm of the common hepatic artery (Picture 1). Melena progressed to frank bright blood in the stools. Hemoglobin dropped to 9.7 gm/dl. Given these findings, vascular surgery and gastroenterology were consulted. He was started on Protonix and Octreotide and over the next two days, his hemoglobin stabilized but continued to have melanotic stools. Patient underwent esophagogastroduodenoscopy (EGD) which was negative for bleeding. Given the HAP and lack of findings during the EGD, he was taken for Hepatic artery stenting (Picture 2). Plavix was initiated post stenting. Post stenting his melena resolved. Patient was sent home with follow up as outpatient and CT scan in 1 month. CT abdomen completed 1 month after stent placement showed a patent stent within the common hepatic artery without an extravasation of contrast into previous pseudoaneurysm.
Discussion: This case illustrates the importance of keeping a broad differential in a patient with complex past gastrointestinal history, presenting with a common chief complaint. In the case presented, it is hypothesized that the origin of his HAP was secondary to his chronic pancreatitis leading to hemosuccus pancreaticus resulting in acute gastrointestinal bleed. This case was unique in that most hemosuccus pancreaticus involve splenic artery pseudoaneurysm instead of HAP. Overall, identification of HAP is important given the high risk of rupture and mortality rate ranging from 25-70%. Definitive treatment surgically or endovascular is necessary for all HAPs. As presented in the case, diagnosis of HAP is critical as it can be the source of a sentinel bleed in patients presenting with an acute gastrointestinal bleed and should be considered in the differential for all gastrointestinal bleeds.
Citation: Kyle Fischer, MD, Melissa Jordan, MD, Wesam Frandah, MD. P0947 - HEMOSUCCUS PANCREATICUS SECONDARY TO HEPATIC ARTERY PSEUDOANEURYSM PRESENTING AS ACUTE GASTROINTESTINAL BLEED. Program No. P0947. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.