Endoscopic ultrasonography-guided obliteration of the left inferior phrenic artery pseudoaneurysm bleed in a patient with alcoholic chronic pancreatitis

Abstract

Background:Bleeding due to a pseudoaneurysm is a life-threatening condition in chronic pancreatitis. Pseudoaneurysm is usually obliterated by digital subtraction angiography (DSA) and embolization. We report a rare case of recurrent pesudoaneurysmal bleed from the left inferior phrenic artery which was obliterated by endoscopic ultrasound (EUS)-guided N-butyl 2-cyanoacrylate glue injection, after failed DSA.Case Report:A 43-year male, chronic alcoholic and smoker, was diagnosed as a case of alcoholic chronic pancreatitis based on imaging. He presented with massive upper gastrointestinal bleed (UGIB) with shock to emergency. His gastroduodenoscopy and colonoscopy were normal. Computed tomographic angiography revealed contrast extravasation from left inferior phrenic artery, but DSA was not technically possible. He had two more episodes of UGIB in 3 months’ duration. Percutaneous thrombin (500 units) was injected with subsequent thrombosed pseudoaneurysm on Doppler study. However, he had another episode of bleeding and an EUS examination showed large revascularized pseudoaneurysm (3.6 cm × 2.3 cm). It was obliterated with EUS-guided 3 mL N-butyl 2-cyanoacrylate glue (1:1 dilution with lipoidal) injection with 22-gauge EUS-guided fine needle aspiration needle. In the same session, two more glue injections completely obliterated the pseudoaneurysm.Conclusions:Left inferior phrenic artery pseudoaneurysm is a very rare cause of UGIB in chronic pancreatitis. Due to technical difficulty during DSA, it could be managed with EUS-guided N-butyl 2-cyanoacrylate glue injection.