An Unusual Presentation of a Left Gastric Artery Pseudoaneurysm

Abstract

A 41 year-old male with no significant past medical history was admitted for nausea, hematemesis, and abdominal pain. On presentation, hemoglobin was 12.5 mg/dL (baseline 15 mg/dL), ALP 64 U/L, AST 21 U/L, ALT 16 U/L, lipase 32 U/L, and total bilirubin 0.6 mg/dL. Stool guaiac was mildly positive. The patient denied any recent aspirin or ibuprofen use. He used tobacco intermittently but denied current alcohol use. Computed tomography (CT) with intravenous and oral contrast showed a 5 cm lobular mass that projected superiorly from the body/tail of the pancreas and displaced the lesser curvature of the stomach. Gastroenterology was consulted for further evaluation. Esophagogastroduodenoscopy (EGD) showed gastric fundal varices with oozing and extrinsic compression of the duodenal bulb. The liver appeared normal on imaging and the platelet count, INR, and liver function tests were within normal limits making intrinsic liver disease unlikely. As compression of splenic vessels can lead to gastric varices, additional imaging was ordered to further evaluate the mass. Magnetic resonance cholangiopancreatography (MRCP) showed a large 5 cm highly vascular mass with indeterminate origin and suggested doppler sonography for further evaluation. Ultrasound showed an anechoic structure with strong arterial flow along its periphery. An abdominal arteriogram confirmed a large gastric pseuduoaneurysm measuring 5.3 x 2.2 cm arising from a branch of the left gastric artery. Successful coil embolization of the pseudoaneurysm was performed and the patient had complete resolution of his symptoms. Follow-up CT one month later showed significant improvement in the size of the pseudoaneurysm. Pancreatitis with or without pseudocyst or abscess formation is the major etiologic factor for pseudoaneurysm formation. Pseudoaneurysms are a known but relatively uncommon complication of acute pancreatitis that has been shown to occur in up to 10% of cases. The splenic artery is most commonly affected followed by the gastroduodenal, pancreaticoduodenal, gastric, and hepatic arteries. Our patient had a lipase within normal limits, no epigastric pain, and no imaging findings to support acute or chronic pancreatitis and no history of trauma making this case exceedingly rare. It is reported that 40-60% of ruptured pseudoaneurysms result in a fatal outcome. Thus, when an extrinsic mass is found to compress the stomach the differential diagnosis of a pseudoaneurysm should be considered.Figure 1Figure 2Figure 3