1969 Splenic Artery Pseudoaneurysm Presenting as GI Bleed: A Diagnostic Conundrum

Abstract

INTRODUCTION: The splenic artery is a common site of visceral artery pseudoaneurysms following the aorta and iliac arteries. It is a rare complication of pancreatitis (52% of cases), abdominal trauma, post-op complications and peptic ulcer disease. This report discusses a patient with recurrent pancreatitis, admitted for upper GI bleed who was found to have a SAP. CASE DESCRIPTION/METHODS: A 25-year-old man with history of recurrent pancreatitis complicated by pseudocyst status post cyst-gastrostomy, presents with 1 week of fatigue, dyspnea and a sensation of “fluids sloshing around” in his abdomen. He noted dark black stools, and had an episode of hematemesis. There was no blood per rectum. Hemoglobin was 6.5 and he was poorly responsive to transfusions. A CTAP revealed a 10 × 4 × 7 mm pseudoaneurysm arising off the proximal splenic artery without active arterial bleed. He was thought to have a brisk upper GI bleed, right-sided colonic bleed or a fistula between the GI tract and splenic artery. An EGD was aborted as it revealed >500cc of blood in the gastric body, after which the patient underwent emergent IR coil embolization of the SAP via the femoral artery. The patient received a total of 6 units of pRBCs, 1 unit of FFP and platelets each during his hospital course. He remained hemodynamically stable off vasopressors, with repeat hemoglobin of 8. DISCUSSION: Recurrent pancreatitis causes enzymatic digestion of the splenic arterial wall, leading to elastic tissue fragmentation, resulting in SAP formation. It is also hypothesized that a long-standing pseudocyst (as in the case of our patient) can induce SAP due to vascular erosion from enzymes within the pseudocyst. While ∼2.5% of cases are found incidentally, most reported cases present with abdominal pain, GI bleed, hemosuccus pancreaticus and hematemesis. A patient with recurrent pancreatitis presenting with persistent anemia or GI bleed without obvious explanation should be managed with a high clinical index of suspicion for SAP. SAPs carry a 35% risk of rupture, and must be promptly managed due to mortality rates reaching 90% if left untreated. While it is challenging to diagnose SAP that presents as GI bleed, the patient’s history of recurrent pancreatitis increases the likelihood of SAP. Once the SAP is detected via imaging, the exact location, size and risk of rupture must be communicated to perform the correct form of treatment, with an aim to prevent life-threatening bleeds, and preferably preserve the spleen for its immunologic functions.