S2196 Splenic Artery Pseudoaneurysm Hemorrhage

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INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a common disorder within the medical field. UGIB accounts for up to 75% of all acute GIBs and can have multiple etiologies, with the most common being peptic ulcer disease. One etiology not often seen is acute hemorrhage from a splenic artery pseudoaneurysm (SAP). Usually, SAPs are rare anatomic variances seen in trauma or pancreatitis. Unlike splenic artery aneurysms (SAA), SAPs are typically found in symptomatic patients at the time of a UGIB. Our case highlights a patient who presented with a massive GIB from a fundic ulcer secondary to a penetrating (SAP). CASE DESCRIPTION/METHODS: An 81 year-old-male who presented via transfer secondary to concerns of UGIB. Esophagogastroduodenoscopy (EGD) prior to transfer revealed no active bleeding, but significant clot burden within the stomach. The EGD was aborted when the patient converted to AF with rapid ventricular rate. Rate control was achieved with beta-blocker therapy and subsequently transferred to our facility, receiving 2 units of packed red blood cells (PRBC) prior to transfer. EGD at our facility revealed multiple, cratered, fundic ulcers without bleeding stigmata or clot burden, requiring no initial therapy. Overnight, the patient would have multiple episodes of hematemesis requiring multiple PRBC transfusions . Repeat EGD revealed significant clot burden and stigmata of bleeding. Attempts were made to evaluate the ulcer underneath the clot burden, however, this resulted in active bleeding. Hemostasis was not achieved with epinephrine injection. General surgery was contacted and unable to offer assistance. Interventional radiology was contacted and performed angiography with coiling of the upper division of the splenic artery involving two large left supra abdominal splenic arterial branches believed to be short gastric-arterial pseudoaneurysms. Hemodynamic stability was achieved but the patient remained intubated. The decision was made to transfer to a tertiary center for higher level management. DISCUSSION: While the majority of SAAs are asymptomatic, SAPs are often found in symptomatic patients. The majority of SAP hemorrhage usually arise from pancreatitis or trauma. In our case, it is believed that his previous fundic ulcers likely resulted in penetration into the SAP causing a massive UGIB. Because our case had neither trauma nor pancreatitis, it exemplifies a rare presentation UGIB caused by splenic artery pseudoaneurysms.Figure 1.: Fundic ulcer.Figure 2.: Pseudoaneurysm present before coil procedure by IR.Figure 3.: Post coil procedure by IR.