A Rare Case of Pancreatic Pseudocyst with Gastroduodenal Artery Aneurysm Secondary to Chronic Pancreatitis: A Case Report

Article Information

Amol S Rathod*, Santosh D Thorat, Akshay C Mhase, Ashutosh S Patil, Rajendra N Wabale

Department of General surgery, PCMC’S PGI YCMH, Pimpri, Pune, Maharashtra, India

*Corresponding Author: Amol Shaligram Rathod, Department of General surgery, PCMC’S PGI YCMH, Pimpri, Pune, Maharashtra, India.

Received: 26 December 2023; Accepted: 03 January 2024; Published: 12 January 2024

Citation: Amol Shaligram Rathod, Santosh Dashrathrao Thorat, Akshay Changdeo Mhase, Ashutosh Sanjay Patil, Rajendra Namdeo Wabale. A Rare Case of Pancreatic Pseudocyst with Gastroduodenal Artery Aneurysm Secondary to Chronic Pancreatitis: A Case Report. Journal of Surgery and Research. 7 (2024): 17-19.

View / Download Pdf Share at Facebook

Abstract

Gastro-duodenal artery aneurysms (GDAAs) are a rare and potentially life-threatening vascular condition with pancreatitis as most common underlying condition. They often remain asymptomatic until rupture, which can lead to catastrophic haemorrhage and mortality. Clinical assessment and radiological.

Investigations should be implicated in timely fashion to diagnose such rare cases. We report a successfully managed case of gastroduodenal artery aneurysm in a patient with chronic pancreatitis.

Keywords

Gastroduodenal artery aneurysm, Pancreatitis, Excision, Visceral artery aneurysm, Case report

Gastroduodenal artery aneurysm articles; Pancreatitis articles; Excision articles; Visceral artery aneurysm articles; Case report articles

Gastroduodenal artery aneurysm articles Gastroduodenal artery aneurysm Research articles Gastroduodenal artery aneurysm review articles Gastroduodenal artery aneurysm PubMed articles Gastroduodenal artery aneurysm PubMed Central articles Gastroduodenal artery aneurysm 2023 articles Gastroduodenal artery aneurysm 2024 articles Gastroduodenal artery aneurysm Scopus articles Gastroduodenal artery aneurysm impact factor journals Gastroduodenal artery aneurysm Scopus journals Gastroduodenal artery aneurysm PubMed journals Gastroduodenal artery aneurysm medical journals Gastroduodenal artery aneurysm free journals Gastroduodenal artery aneurysm best journals Gastroduodenal artery aneurysm top journals Gastroduodenal artery aneurysm free medical journals Gastroduodenal artery aneurysm famous journals Gastroduodenal artery aneurysm Google Scholar indexed journals Pancreatitis articles Pancreatitis Research articles Pancreatitis review articles Pancreatitis PubMed articles Pancreatitis PubMed Central articles Pancreatitis 2023 articles Pancreatitis 2024 articles Pancreatitis Scopus articles Pancreatitis impact factor journals Pancreatitis Scopus journals Pancreatitis PubMed journals Pancreatitis medical journals Pancreatitis free journals Pancreatitis best journals Pancreatitis top journals Pancreatitis free medical journals Pancreatitis famous journals Pancreatitis Google Scholar indexed journals Excision articles Excision Research articles Excision review articles Excision PubMed articles Excision PubMed Central articles Excision 2023 articles Excision 2024 articles Excision Scopus articles Excision impact factor journals Excision Scopus journals Excision PubMed journals Excision medical journals Excision free journals Excision best journals Excision top journals Excision free medical journals Excision famous journals Excision Google Scholar indexed journals Visceral artery aneurysm articles Visceral artery aneurysm Research articles Visceral artery aneurysm review articles Visceral artery aneurysm PubMed articles Visceral artery aneurysm PubMed Central articles Visceral artery aneurysm 2023 articles Visceral artery aneurysm 2024 articles Visceral artery aneurysm Scopus articles Visceral artery aneurysm impact factor journals Visceral artery aneurysm Scopus journals Visceral artery aneurysm PubMed journals Visceral artery aneurysm medical journals Visceral artery aneurysm free journals Visceral artery aneurysm best journals Visceral artery aneurysm top journals Visceral artery aneurysm free medical journals Visceral artery aneurysm famous journals Visceral artery aneurysm Google Scholar indexed journals chronic pancreatitis articles chronic pancreatitis Research articles chronic pancreatitis review articles chronic pancreatitis PubMed articles chronic pancreatitis PubMed Central articles chronic pancreatitis 2023 articles chronic pancreatitis 2024 articles chronic pancreatitis Scopus articles chronic pancreatitis impact factor journals chronic pancreatitis Scopus journals chronic pancreatitis PubMed journals chronic pancreatitis medical journals chronic pancreatitis free journals chronic pancreatitis best journals chronic pancreatitis top journals chronic pancreatitis free medical journals chronic pancreatitis famous journals chronic pancreatitis Google Scholar indexed journals mortality rate articles mortality rate Research articles mortality rate review articles mortality rate PubMed articles mortality rate PubMed Central articles mortality rate 2023 articles mortality rate 2024 articles mortality rate Scopus articles mortality rate impact factor journals mortality rate Scopus journals mortality rate PubMed journals mortality rate medical journals mortality rate free journals mortality rate best journals mortality rate top journals mortality rate free medical journals mortality rate famous journals mortality rate Google Scholar indexed journals alcohol consumption articles alcohol consumption Research articles alcohol consumption review articles alcohol consumption PubMed articles alcohol consumption PubMed Central articles alcohol consumption 2023 articles alcohol consumption 2024 articles alcohol consumption Scopus articles alcohol consumption impact factor journals alcohol consumption Scopus journals alcohol consumption PubMed journals alcohol consumption medical journals alcohol consumption free journals alcohol consumption best journals alcohol consumption top journals alcohol consumption free medical journals alcohol consumption famous journals alcohol consumption Google Scholar indexed journals C-reactive protein articles C-reactive protein Research articles C-reactive protein review articles C-reactive protein PubMed articles C-reactive protein PubMed Central articles C-reactive protein 2023 articles C-reactive protein 2024 articles C-reactive protein Scopus articles C-reactive protein impact factor journals C-reactive protein Scopus journals C-reactive protein PubMed journals C-reactive protein medical journals C-reactive protein free journals C-reactive protein best journals C-reactive protein top journals C-reactive protein free medical journals C-reactive protein famous journals C-reactive protein Google Scholar indexed journals cysto-gastrostomy articles cysto-gastrostomy Research articles cysto-gastrostomy review articles cysto-gastrostomy PubMed articles cysto-gastrostomy PubMed Central articles cysto-gastrostomy 2023 articles cysto-gastrostomy 2024 articles cysto-gastrostomy Scopus articles cysto-gastrostomy impact factor journals cysto-gastrostomy Scopus journals cysto-gastrostomy PubMed journals cysto-gastrostomy medical journals cysto-gastrostomy free journals cysto-gastrostomy best journals cysto-gastrostomy top journals cysto-gastrostomy free medical journals cysto-gastrostomy famous journals cysto-gastrostomy Google Scholar indexed journals pseudo aneurysm articles pseudo aneurysm Research articles pseudo aneurysm review articles pseudo aneurysm PubMed articles pseudo aneurysm PubMed Central articles pseudo aneurysm 2023 articles pseudo aneurysm 2024 articles pseudo aneurysm Scopus articles pseudo aneurysm impact factor journals pseudo aneurysm Scopus journals pseudo aneurysm PubMed journals pseudo aneurysm medical journals pseudo aneurysm free journals pseudo aneurysm best journals pseudo aneurysm top journals pseudo aneurysm free medical journals pseudo aneurysm famous journals pseudo aneurysm Google Scholar indexed journals

Article Details

Introduction

Visceral artery aneurysms are clinical entities labelled any artery that are intra abdominal other than aortoiliac axis .VAAs are rare clinical entities with 0.01%-0.2% incidence out of which 10% has been reported among chronic pancreatitis patients [1]. However, they could be lethal with potential of  25% risk of rupture; which consequently has a mortality rate of 70% [2,3]. Gastro duodenal artery (GDA) aneurysm is among the rarest VAAs; accounting only for 1.5% of the total. After inferior mesenteric artery aneurysm, gastroduodenal artery aneurysm lies on second highest position for its rarity [4]. GDA aneurysm have 75% risk of rupture representing it as a important subcategory of VAAs [5] with gastrointestinal bleeding being the presenting feature in up to 52% of cases [6].

Case Report

A 48 year male came in emergency with complains of pain in the abdomen since 8 days patient was chronic alcoholic and mentioned history of binge alcohol consumption in last 10 days with history of acute pancreatitis earlier. On physical examination, his abdomen was flat, soft, tenderness was present in epigastric region without guarding and rigidity . Laboratory data showed a red blood cell count of 440x104/|il, C-reactive protein (CRP) was elevated to 6.3 mg/dl (normal range, 0-0.5), total bilirubin (T-Bil) 1.7 mg/dl (0. 1-1.2) , asparate-aminotransferase (AST) 115 IU/L(12-33), alanine aminotransferase (ALT) 85 IU/L (5-35), alkaline phosphatase (ALP) 95 IU/L (90-298), y – glutamyl transpeptidase (y-GTP) 55 IU/L (12-75), serum amylase (S-Amy) 387 IU/L (40-130), serum lipase 395 IU/L.

ultrasonography report suggestive of acute necrotizing pancreatitis with peri pancreatic collection of size 9.5*10.2 cm.[App. Vol 150cc]

Contrast enhanced computer tomography suggestive of generalised atrophic pancreas with periphery enhancing cystic lesion of size 11.6*10.5*10.2 cm.

In distal pancreatic body. There is evidence of intensely enhancing lesion of size 2.7*3.6*3.8 cm noted in upper abdomen adjacent to head of pancreas and duodenum. This lesion is seen in continuation with the gastroduodenal branch of common hepatic artery suggestive of arterial aneurysm (Figure 2).

The diagnosis on clinical and radiological basis patient was optimised and planned for exploratory laparotomy for cysto-gastrostomy and GDA ligation and excision.

Operative procedure initiated with mid line laparotomy incision pancreatic bed accessed and pseudocyst visualise. Pseudocyst confirmed with needle aspiration and cysto-gastrostomy performed. Further dissection progressed to coeliac trunk visualisation. Celiac axis visualised and secured with further vascular dissection with visualisation of  Right gastric artery, common hepatic artery, left and right hepatic artery, gastroduodenal artery along with its aneurysm visualised (Figure 1). Posterior feeding supply of aneurysm clipped with silicon haemoclip and redundant part excised en-bloc. Haemostasis was maintained  throughout the surgery. Abdominal drain placed in pelvis and cysto-gastrostomy bed. Post operatively all routine labs evaluated on day 2 and are as follows HB-12 mg/dl, tlc-8000/ml, platelet- 126000. Drain amylase and lipase value evaluated on day 2 and values are as follows 20 and 28. Drain removed on day 3. Histopathology report was consistent with non specific inflammation with irregular walled congested vessel. The  patient was discharged on day 6.

fortune-biomass-feedstock

Figure 1: Intra operative image showing visceral arteries and aneurysmal part of gastroduodenal artery.

fortune-biomass-feedstock

Figure 2: CECT images with vascular reconstruction  showing pancreatic pseudocyst with GDA aneurysm.

2A: Vascular reconstruction of computed tomography demonstrating gastroduodenal artery aneurysm; 2B: CECT image demonstrating pancreatic pseudocyst with GDA aneurysm.

Discussion

Gastroduodenal artery aneurysm reported to be rare form. Depending on morphology GDA aneurysm is classified into false and true aneurysm. Common causes reported for GDA aneurysm are chronic pancreatitis, arteriosclerosis, surgical trauma. Other causes are congenital absence of celiac axis, iatrogenic injury during biopsy of head of pancreas and tuberculous infection. In this case repeated bouts of pancreatitis formed to be the underlying cause as it is also associated with pancreatic pseudocyst and leakage of proteolytic enzymes due to pancreatitis leads to vessel wall damage and formation of pseudo aneurysm .If the patient is hemodynamically stable endovascular embolization is gold standard method [7]. Once diagnosed, a GDA must be definitively treated even if small or asymptomatic. On account of its potential to rupture; a drastic event which seems to be unrelated to size. The optimal management approach depends on the mode of presentation and hemodynamic status of the patient [8]. But in this case a pancreatic pseudocyst formed a additional pathology needed to be managed and it can also lead to alter the prognosis. To avail this open surgical procedure is preffered in this case.

Conclusion

Gastroduodenal artery aneurysm are rare entity most common secondary to chronic pancreatitis. As this condition is latent with sudden grave consequences  excision of the aneurysm is feasible and safer.

Disclosure statement

All authors have no conflict of interest.

References

  1. Røkke O, Søndenaa K, Amundsen S, et al. The diagnosis and management of splanchnic artery aneurysms. Scand J Gastroenterol 31 (1996): 737-743.
  2. Panayiotopoulos YP, Assadourian R, Taylor PR. Aneurysms of the visceral and renal arteries. Ann R Coll 3 of 4 Surg Engl 78 (1996): 412-419.
  3. Gehlen JM, Heeren PA, Verhagen PF, et al. Visceral artery aneurysms. Vasc Endovascular Surg 45 (2011): 681-687.
  4. Edogawa S, Shibuya T, Kurose K, et al. Inferior mesenteric artery aneurysm: case report and literature review. Ann Vasc Dis 12 (2013): 98-101.
  5. Harris K, Chalhoub M, Koirala A. Gastroduodenal artery aneurysm rupture in hospitalized patients: An overlooked diagnosis. World J Gastrointest Surg 27 (2010): 291-294.
  6. Habib N, Hassan S, Abdou R, et al. Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review. Ann Surg Innov Res 16 (2013): 4.
  7. Morita Y, Kawamura N, Saito H, et al. Diagnosis and embolotherapy of aneurysm of the gastroduodenal artery. Rinsho Hoshasen 33 (1988): 555-561.
  8. McGuire A, Capron B. Outpatient Management of Gastroduodenal Artery Aneurysm. Cureus 28 (2021): 19091.

© 2016-2024, Copyrights Fortune Journals. All Rights Reserved