A Ruptured Omental Aneurysm, a Rare Cause of Intraabdominal Bleeding Steven Jacobs, Sabrina Houthoofd, Inge Fourneau, and Kim Daenens, Leuven, Belgium

Of all splanchnic artery aneurysms, the omental artery aneurysm is the most uncommon. In the published literature, there is no report of an incidental diagnosis, and all were discovered only after rupture. Until now, this is only the sixth case of a ruptured omental aneurysm published, and the first case with a concomitant nonruptured omental aneurysm.

CASE REPORT A 63-year-old man consulted his general physician for abdominal discomfort. There were no other gastrointestinal problems. His medical history consisted of obesity (body mass index: 33.7 kg/m2), noneinsulin-dependent diabetes, and atrial fibrillation for which he was treated with warfarin and a beta-blocker. The clinical findings were reassuring, so blood samples were taken and the patient was sent home. Laboratory results revealed a hemoglobin of 8.3 g/dL and an international normalized ratio of 4, suggesting bleeding because of a disordered international normalized ratio. In the interim, the patient’s abdominal pain became more profound and his condition deteriorated rapidly; the patient was referred to the emergency department. The clinical examination revealed a pale patient with a blood pressure of 86/53 mm Hg and an irregular pulse of 70 beats/min. His abdomen was clearly distended, but there was no real tenderness. Fast ultrasound of the abdomen revealed a large hemoperitoneum. The aorta was not visualized, partially because of the patient’s obesity, but because the patient was obviously in hypovolemic shock, the tentative diagnosis of a ruptured aortic aneurysm was made. He received prothrombin complex concentrates and was immediately transferred to the operation room. During induction, his blood pressure dropped to 40/ 30 mm Hg. A median laparotomy was performed with Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium. Correspondence to: Steven Jacobs, MD, Catholic University Leuven, UZ Leuven, Campus Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium; E-mail: [email protected] Ann Vasc Surg 2014; 28: 491.e9–491.e11 http://dx.doi.org/10.1016/j.avsg.2013.02.028 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: November 12, 2012; manuscript accepted: February 7, 2013; published online: November 25, 2013.

immediate drainage of sanguineous peritoneal fluid. An infrarenal aortic clamp was placed and exploration of the abdominal aorta and iliac arteries revealed normal sizes and no rupture at all. Despite the aortic clamp, his blood pressure dropped again and therefore the clamp was moved to a supraceliac position. Because this resulted in a sustained recovery of his blood pressure, we had to look for bleeding from a visceral artery. The renal arteries were intact and starting to spread the omentum, and we discovered a bleeding from a ruptured omental aneurysm. The omental artery was selectively clamped proximal and distal to the rupture, and the aortic clamp was removed. His blood pressure remained stable and the aneurysm was resected with ligation of the omental artery (Fig. 1). Further exploration revealed another aneurysm in the omentum, resected in the same way (Fig. 2). No other visceral aneurysms were detected. The patient received 6 units of packed red blood cells. Postoperatively, the patient required hemodialysis for a few days in the intensive care unit, but further recovery was uneventful and he was discharged from the hospital after 7 days. The histologic analysis confirmed aneurysmatic dilatation of both vascular structures. One of these revealed destruction of the normal layers of the vascular wall because of rupture (Fig. 3). One year later, patient is doing well and has a normal renal function.

DISCUSSION With an incidence of

A ruptured omental aneurysm, a rare cause of intraabdominal bleeding.

Of all splanchnic artery aneurysms, the omental artery aneurysm is the most uncommon. In the published literature, there is no report of an incidental...
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