Single Cause, Dual Presentation: Inferior Pancreatico-duodenal Artery Pseudoaneurysm as a Cause of Hemorrhagic Shock and Obstructive Jaundice

Abstract

Pseudoaneurysm of the inferior pancreaticoduodenal artery (IPDA) is very rare. We report the case of a patient with hemorrhagic shock secondary to a bleeding pseudoaneurysm of the IPDA, also causing obstructive jaundice by virtue of its size and location. To our knowledge, this is the first such reported case in the United States. A 45-year-old male with history of iron deficiency anemia, chronic pancreatitis and alcohol abuse presented with severe right upper quadrant (RUQ) abdominal pain for 1 week. On presentation, vitals were stable and physical examination revealed RUQ abdominal tenderness and scleral icterus. Laboratory study showed hemoglobin 6.1 g/dl, alkaline phosphatase 416U/L, GGT 230 U/L, AST 76 U/L, ALT 132 U/L, total bilirubin 4.4 mg/dl, and direct bilirubin 3.4 mg/dL. Computed tomography (CT) of the abdomen with intravenous contrast showed a pseudoaneurysm arising from the IPDA (6.5x4.1x4.3 cm), acute on chronic pancreatitis and obstruction of biliary tree due to mass effect from pseudoaneurysm, marked intra and extrahepatic biliary dilation with the common bile duct measuring 17 mm and distended gallbladder. Mesenteric angiography also revealed the aneurysm but not amenable to embolization. The patient's abdominal pain worsened and developed hemorrhagic shock requiring additional resuscitation. Stat CT angiography showed increased size of the pseudoaneurysm, and a new hyperdense material within the small bowel loops. Exploratory laparotomy revealed large amount of intraluminal blood in second part of duodenum and a large pseudo aneurysm entering second part of duodenum that was ligated. Distal gastrectomy with duodenotomy with lysis of adhesions was done. LFTs trended down and jaundice resolved after procedure. Pseudoaneursym of IPDA is a rare complication of chronic pancreatitis. The mortality is 90-100% with acute hemorrhage in untreated patients and 12-50% even with aggressive treatment. Even though, most common presentation of pseuodaneusym is acute GI bleed, other presentations should not be overlooked. As shown in this case, our patient presented with obstructive jaundice. Direct pressure over the pancreaticobiliary ducts can cause recurrent pancreatitis and jaundice. Mesenteric angiography is the gold standard diagnostic test. Treatment options include angiographic embolization and surgical treatment. Early multidisciplinary approach with diagnostic and therapeutic interventions is needed to improve the outcome and decrease mortality.Figure: CT abdomen with contrast: Pseudoaneursym of inferior pancreaticoduodenal artery (arrow).Figure: Mesenteric Angiography:Pseudoaneursym of inferior pancreaticoduodenal artery(arrow).