Peri-esophageal Pseudoaneurysms: Unique Cause of Refractory Arterial Bleeding Treated With Novel Technique

Abstract

A 43 year old female with SLE and dysplastic Barrett's esophagus (Prague class C8 M9) treated with radiofrequency ablation presented with hematemesis. An EGD showed esophageal ulcers without any active bleeding. After 2 days of conservative treatment, the patient had an episode of hematochezia and syncope. Colonoscopy showed fresh blood throughout the colon as well as terminal ileum without any source. EGD showed a large esophageal ulcer with active bleeding. Endoscopic clips did not stop the bleeding. A Sengstaken Blakemore tube was placed. Patient was taken to Interventional radiology suite where brisk active bleeding into the distal esophagus from esophageal branches of the left gastric artery was seen. The arteriogram showed saccular dilation/pseudo-aneurysms that were the source of bleeding (arrow, Figure 1). Gel-foam embolization of the left gastric and esophageal branches, coil embolization of the gastrohepatic trunk and particle embolization of the pseudo-aneurysms stopped the bleeding. Esophageal brushings showed active cytomegalovirus infection along with low complement levels consistent with active vasculitis from SLE and mixed connective tissue disease. The patient eventually underwent exploratory laparotomy with resection of a necrotic esophago-gastric junction as well as thoracic esophagectomy. Pathological evaluation showed submucosal hemorrhage, esophagitis with dysplastic Barrett's mucosa and an ulcer containing cytomegaloviral inclusions. It is probable that the ulcer from cytomegalovirus eroded into the pseudo-aneurysm formed by the persistent SLE mediated vasculitis and lead to the refractory bleeding.Figure 1We report the first case of arterial bleeding from peri-esophageal pseudo-aneurysms present in the aortoesophageal branches in the left gastric arcade. We also report the use of gel-foam and particle embolization for arterial bleeding in the esophagus.