Journal of the Formosan Medical Association (2014) 113, 756e757
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CORRESPONDENCE
Spontaneous pseudoaneurysm rupture of gastroduodenal artery: A rare and lifethreatening condition of back pain Chang-Feng Huang a, Yin-Tzu Liu b, Yi-Ching Wu a, Yu-Ming Bai a, Yu-Hang Yeh a, Tzu-Yao Hung a,* a b
Emergency Department, Zhongxing Branch of Taipei City Hospital, Taiwan Ophthalmology Department, Zhudong Veterans Hospital, Taiwan
Received 1 August 2012; received in revised form 30 August 2012; accepted 31 August 2012 A 54-year-old man suffered from a sudden midline back soreness while watching television 20 minutes before presenting to our emergency department. He had a history of hypertension and peptic ulcer disease. His body temperature was 35.2 C, blood pressure was 179/108 mmHg, pulse rate was 58 beats/minute, and respiratory rate was 20 breaths/minute. He denied recent trauma, abdominal surgery, alcohol consumption, or vascular disease history. On physical examination, he had mild fullness in the epigastric region. There was no significant abdominal tenderness, no abdominal palpable mass, nor flankknocking tenderness. An irregular hypoechoic mass located in the upper abdomen was detected by ultrasound examination at the bedside. There was no hydronephrosis, no significant amount of ascites, and no pericardial effusion. The complete blood count, prothrombin time, activated partial thromboplastin time, and biochemistry tests including amylase (49 U/L) and lipase (78 U/L) were unremarkable. Abdominal computed tomography (CT) showed a huge retroperitoneal hematoma with contrast medium extravasation (Fig. 1). Three-dimensional CT demonstrated
Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Number 145, Zhengzhou Road, Datong District, Taipei City 103, Taiwan, ROC. E-mail address:
[email protected] (T.-Y. Hung).
a pseudoaneurysm of the gastroduodenal artery (GDA). Meanwhile, blood pressure dropped to 93/59 mmHg. Fluid resuscitation and blood transfusions with eight units of packed blood cells and eight units of fresh frozen plasma were given via a central venous catheter. Transcatheter arterial embolization was performed but failed to stop the bleeding. In spite of strong advice by the surgeon, the family refused permission for him to undergo the operation. He developed bradycardia and expired 15 hours after symptoms onset. Rupture of a GDA pseudoaneurysm is an extremely rare and life-threatening condition. The diagnosis is challenging even for the most seasoned emergency physicians. Clinical presentations of GDA pseudoaneurysm vary widely, from massive gastrointestinal bleeding, obstructive jaundice, unexplained collapse, abdominal pain, and in our case, serious back soreness.1,2 Several conditions may lead to GDA pseudoaneurysm formation and subsequent rupture, such as complications after pancreaticoduodenectomy, chronic pancreatitis, trauma, tuberculosis, and septic emboli.3e5 However, there was no clinically significant acute or chronic pancreatitis history in our patient and the risk factors for chronic pancreatitis were absent. Although the standard diagnostic tool for a GDA pseudoaneurysm is angiography, CT angiography can nonetheless suggest the diagnosis and is more practical in the emergency department.
0929-6646/$ - see front matter Copyright ª 2012, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. http://dx.doi.org/10.1016/j.jfma.2012.08.019
Spontaneous pseudoaneurysm rupture
Figure 1
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The bleeding source from the gastroduodenal artery was demonstrated on 3D-CT.
In conclusion, GDA pseudoaneurysm needs aggressive management. Early transcatheter arterial embolization and emergent operation are essential to avoid adverse results.
References 1. Elazary R, Abu-Gazala M, Schlager A, Shussman N, Rivkind 1 AI, Bloom AI. Therapeutic angiography for giant bleeding gastroduodenal artery pseudoaneurysm. World J Gastroenterol 2010;16:1670e2. 2. Bohl JL, Dossett LA, Grau AM. Gastroduodenal artery pseudoaneurysm associated with hemosuccus pancreaticus and obstructive jaundice. J Gastrointest Surg 2007;11:1752e4.
3. Hur S, Yoon CJ, Kang SG, Dixon R, Han HS, Yoon YS, et al. Transcatheter arterial embolization of gastroduodenal artery stump pseudoaneurysms after pancreaticoduodenectomy: safety and efficacy of two embolization techniques. J Vasc Intervent Radiol 2011;22:294e301. 4. Klauss M, Heye T, Stampfl U, Grenacher L, Radeleff B. Successful arterial embolization of a giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis with literature review. J Radiol Case Rep 2012;6: 9e16. 5. Tulsyan N, Kashyap VS, Greenberg RK, Sarac TP, Clair DG, Pierce G, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007;45:276e83.
