Massive Upper GI Bleed Secondary to Splenic Artery Pseudoaneurysm

Abstract

Purpose: 22 year old male, history of abdominal trauma, presented with sudden onset of 3 episodes of hematemesis associated with abdominal pain and loss of consciousness. He denied previous episodes of GI bleeding. Two years prior, he had multiple stab wounds to the abdomen and subsequently underwent exploratory laparotomy and ostomy with reversal for perforated bowel. Reports heavy alcohol use on weekends and smokes 1 ppd × 6 years. Upon arrival to the emergency room, vital signs were stable: P73, BP 122/68 with no orthostasis. Abd exam: + BS, NT, ND, + midline and ostomy scars, no organomegaly. Rectal exam: brown stool, guaiac positive. NG lavage was not performed. Labs: WBC 11,900 mm3, Hg 12.5 g/dL, Hct 37.9%, Platelets 323/mm3, BUN/cr ratio19 with normal coagulation profile and liver tests. An EGD was performed. A large fresh clot was seen in the gastric body which could not be suctioned. In addition, fresh blood was seen in the second portion of the duodenum, but no source of bleeding was identified. During endoscopy, the patient had several more episodes of hematemesis and was taken to interventional radiology. A 5 F catheter was placed in the celiac axis and an angiogram was performed. A pseudoaneurysm off the mid splenic artery was identified as the source of bleeding and coils were deployed and packed into the pseudoaneurysm. Repeat angiogram showed no residual flow with good thrombosis. Subsequently, the patient was discharged with no further episodes of GI bleeding and Hct 35%. Few cases have reported GI bleeding in patients where pseudoaneurysms have been thought to spontaneously erode into the GI tract secondary to compression/stress/trauma. Since this patient had sustained prior abdominal trauma in the same anatomical location as the formation of the splenic artery pseudoaneurysm, spontaneous fistularization of the pseudoaneurysm and the gastric wall could have occurred thus explaining his presentation. A thorough review of the literature has reported pseuodocyst and pseudoaneurysm fistularization to arteries supplying the GI tract or to the pancreatic duct in patients with chronic pancreatitis resulting in upper GI bleeding. However, to date, there is no reported case of a pseudoaneurysm of the splenic artery caused as a result of prior abdominal and presenting as trauma hematemesis. Hence, as gastroenterologists, we must be aware of the increasing role of angiographical methods for diagnosing and controlling acute GI bleeding.