1987 A Rare Cause of Massive Upper Gastrointestinal Bleeding

Abstract

INTRODUCTION: Pseudoaneurysm (PA) is a rare, life-threatening complication of pancreatitis. Spontaneous PA rupture can cause massive bleeding, and up to 60% of massive bleeding following pancreatitis is due to rupture of PA. PA rupture may be lethal and in cases of diagnostic delayed mortality can be as high as 60 %. There are no known risk factors for PA rupture. We are presenting a case of gastrointestinal (GI) bleeding due to the ruptured splenic artery pseudoaneurysm. We believe this was a delayed complication of AXIOS stent which is a lumen-apposing metal stent (LAMS) used for cystogastrostomy. CASE DESCRIPTION/METHODS: A 30-year-old male with a history of walled off necrosis secondary to alcohol-induced pancreatitis presented with massive hematemesis and lightheadedness. He had undergone cystogastrostomy with LAMS placement three weeks prior. He was taking ibuprofen 800 mg daily. On presentation was in hypovolemic shock. CT scan did not reveal any findings suggestive of bleeding. Esophagogastroduodenoscopy showed bleeding from the LAMS with large clot formation in the stent. The bleeding worsened after attempting to dislodge the clot and did not stop after epinephrine injection. After stabilizing the patient, he underwent CT angiography. It showed a PA arising from the distal splenic artery, directly posterior to the LAMS (Figure 1). The patient was sent for conventional angiography, and multiple coils were placed in the splenic artery near the PA (Figures 2 and 3). He did not have further bleeding. He continued to improve during the hospitalization and was eventually discharged. The LAMS was successfully removed approximately one month after discharge with near resolution of the walled-off necrosis. DISCUSSION: Ruptured PA is a life-threatening complication of pancreatitis. Delayed diagnosis has a mortality of 25 to 60 %. Timely diagnosis and treatment can reduce mortality to less than15%. 4 to 10 % of patients with chronic pancreatitis may be at risk of bleeding due to PA. LAMS has been widely used for endoscopic cystogastrostomy. LAMS due to bi-flanged design stays in the place and achieves the better success of draining a pseudocyst. There are few reported cases of delayed bleeding due to ruptured PA due to LAMS. The provider should have a high suspicion of a ruptured PA once other causes of bleeding are ruled out by an EGD. An urgent CT angiography is the diagnostic test of choice. Embolization of bleeding pseudoaneurysm is the first line of therapy even in critical conditions.