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doi:10.1111/jgh.12603
E D U C AT I O N A N D I M A G I N G
Gastrointestinal: Spontaneous rupture of the pancreaticoduodenal artery from segmental arterial mediolysis
Figure 1
A 50-year-old woman was admitted to our hospital complaining of abdominal pain, vomiting, and diarrhea. She had no history of surgical operations, drug abuse, alcohol intake, or smoking, and no specific family history. At the time of admission, her blood pressure was 180/100 mmHg, and her pulse rate was 107/min with a temperature of 36.8°C. On physical examination, she had upper abdominal pain with mild tenderness. She had no peritoneal signs with muscle guarding. No evidence of obvious arteritis and collagen diseases could be found. Her white blood cell count was 11000/μL, with a hemoglobin level of 15.2 g/dL and a slightly elevated C-reactive protein (3.3 mg/dL). Coagulation studies and other biochemical studies were normal. Despite fluid infusion therapy, the abdominal pain continued. The next day, she was in shock with severe abdominal pain and massive distension. Her hemoglobin decreased to 12.2 g/dL, suggesting massive hemorrhage. A contrast-enhanced abdominal computed tomography image showed massive bleeding of the retroperitoneum and irregular vessel dilatation (Figure 1). Therefore, abdominal angiography was performed immediately. Digital subtraction angiography showed several saccular aneurysms of 1-2 cm in diameter demonstrating a string-of-beads appearance of the pancreaticoduodenal artery (Figure 2, left). Although hemorrhage of the aneurysms was not clearly seen, rupture of the pancreaticoduodenal artery aneurysms with segmental arterial mediolysis (SAM) was diagnosed. Transcatheter coil embolization of the SAM was then successfully performed (Figure 2, right), the bleeding stopped, and the patient’s symptoms disappeared. SAM is a rare, non-inflammatory, non-atherosclerotic vasculopathy characterized by segmental destruction of the arterial media, pathological mediolysis, adventitial-medial junction separation, gaps, and granulation tissue infiltrating within single or multiple vessels. Clinical presentations include a variety of symptoms, such as abdominal pain, shock, hematochezia, or stroke, depending on the affected vessels. Splenic, colonic, and hepatic vessels are most commonly involved. However, multiple SAMs of the pancreaticoduodenal artery are very rare. Hemorrhage from ruptured vessels needs emergent arterial embolization
Figure 2
or immediate surgical treatment, because the mortality rate is high without invasive treatment. Surveillance CT scanning with contrast may be needed to detect SAM early and perform prophylactic treatment. In conclusion, a rare case of spontaneous rupture of SAMs of the pancreaticoduodenal artery successfully treated by intravascular coil embolization was presented. Contributed by T Yamamoto*, N Yoshizawa*, H Fuke*, A Hashimoto*, K Sugimoto†, K Shiraki† & A Shimizu* *Internal Medicine, Saiseikai Matsusaka Hosipital, Matsusaka and †Department of Gastroenterology, Mie University School of Medicine, Tsu, Japan
Journal of Gastroenterology and Hepatology 29 (2014) 1129 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
1129
doi:10.1111/jgh.12603
E D U C AT I O N A N D I M A G I N G
Gastrointestinal: Spontaneous rupture of the pancreaticoduodenal artery from segmental arterial mediolysis
Figure 1
A 50-year-old woman was admitted to our hospital complaining of abdominal pain, vomiting, and diarrhea. She had no history of surgical operations, drug abuse, alcohol intake, or smoking, and no specific family history. At the time of admission, her blood pressure was 180/100 mmHg, and her pulse rate was 107/min with a temperature of 36.8°C. On physical examination, she had upper abdominal pain with mild tenderness. She had no peritoneal signs with muscle guarding. No evidence of obvious arteritis and collagen diseases could be found. Her white blood cell count was 11000/μL, with a hemoglobin level of 15.2 g/dL and a slightly elevated C-reactive protein (3.3 mg/dL). Coagulation studies and other biochemical studies were normal. Despite fluid infusion therapy, the abdominal pain continued. The next day, she was in shock with severe abdominal pain and massive distension. Her hemoglobin decreased to 12.2 g/dL, suggesting massive hemorrhage. A contrast-enhanced abdominal computed tomography image showed massive bleeding of the retroperitoneum and irregular vessel dilatation (Figure 1). Therefore, abdominal angiography was performed immediately. Digital subtraction angiography showed several saccular aneurysms of 1-2 cm in diameter demonstrating a string-of-beads appearance of the pancreaticoduodenal artery (Figure 2, left). Although hemorrhage of the aneurysms was not clearly seen, rupture of the pancreaticoduodenal artery aneurysms with segmental arterial mediolysis (SAM) was diagnosed. Transcatheter coil embolization of the SAM was then successfully performed (Figure 2, right), the bleeding stopped, and the patient’s symptoms disappeared. SAM is a rare, non-inflammatory, non-atherosclerotic vasculopathy characterized by segmental destruction of the arterial media, pathological mediolysis, adventitial-medial junction separation, gaps, and granulation tissue infiltrating within single or multiple vessels. Clinical presentations include a variety of symptoms, such as abdominal pain, shock, hematochezia, or stroke, depending on the affected vessels. Splenic, colonic, and hepatic vessels are most commonly involved. However, multiple SAMs of the pancreaticoduodenal artery are very rare. Hemorrhage from ruptured vessels needs emergent arterial embolization
Figure 2
or immediate surgical treatment, because the mortality rate is high without invasive treatment. Surveillance CT scanning with contrast may be needed to detect SAM early and perform prophylactic treatment. In conclusion, a rare case of spontaneous rupture of SAMs of the pancreaticoduodenal artery successfully treated by intravascular coil embolization was presented. Contributed by T Yamamoto*, N Yoshizawa*, H Fuke*, A Hashimoto*, K Sugimoto†, K Shiraki† & A Shimizu* *Internal Medicine, Saiseikai Matsusaka Hosipital, Matsusaka and †Department of Gastroenterology, Mie University School of Medicine, Tsu, Japan
Journal of Gastroenterology and Hepatology 29 (2014) 1129 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
1129
