Massive Upper Gastrointestinal Bleeding due to Rupture of Splenic Artery Aneurysm Caused by a Hypernephroma

Abstract

Purpose: Upper endoscopy can sometimes be non diagnostic in the patient who presents with acute massive upper gastrointestinal bleeding. This can be due to the large amount of blood in the stomach that can impair visualization of the walls of the stomach. In such patients, early intervention with angiography can be a safe and life saving solution. We present here the case of a 61 year old female who presented to the emergency room with large amounts of hematemesis. Blood pressure was 59/29 mm Hg. Hemoglobin was 6.6 gm%. She underwent an urgent upper endoscopy that showed large amount of blood in the stomach. A bleeding site could not be located and the patient was sent to interventional radiology for an urgent angiography. The celiac axis was catheterized and contrast was seen to be leaking from an aneurysm in the mid main splenic artery. A coaxial micro catheter was placed and the splenic artery distally and proximally was embolized with coils trapping the area of bleeding between the coils. Angiography also showed tangles of vessels extending into the left upper quadrant likely representing neovascularity. A CT scan of the abdomen was therefore done that showed a large mass in the upper pole of the left kidney highly suspicious for renal cell carcinoma. A repeat upper endoscopy done 3 days later showed a large area of ulceration in the posterior wall of the greater curvature of the stomach with small amounts of calcification, likely from the splenic artery aneurysm that was coiled. At surgery, the renal mass was seen to be causing a mechanical obstruction of the splenic artery. In summary, the patient developed renal cell cancer that caused a mechanical obstruction to the splenic artery resulting in aneurysm formation. The splenic artery aneurysm caused the gastric bleeding by rupturing into the posterior wall of the stomach. Discussion: Splenic artery aneurysms are rare. Increased velocity of blood flow through the splenic artery may be an etiological factor. Endovascular embolization is a viable treatment for these patients with an 80-92% success rate. A review of the literature did not show a similar case of a renal mass causing mechanical obstruction and aneurysm formation in the splenic artery and subsequent rupture into the stomach.Figure: No Caption available.