Abstract
A 58 year old female presented to our group for work up of abdominal pain and pancreatic mass revealed on a previously obtained abdominal CT scan. She had past medical history significant for type 2 diabetes, arthritis, and hypertension. She had no history of abdominal surgeries, and specifically denied history of alcohol use. Physical exam revealed a soft abdomen and no hepatosplenomegaly. Her laboratory studies including a CA 19-9 were unremarkable. EGD with endoscopic ultrasound (EUS) was performed and a 16 mm x 17 mm round, well-defined, hypoechoic exophytic lesion in the posterior pancreatic head (not involving the PD) was noted. This lesion was abutting the major veins at the portal confluence, however there was no evidence of invasion into the vessels. Elastographic EUS showed a predominantly solid mass. Based on the EUS, the differential diagnosis included neuroendocrine tumor and rare lymphoepithelial keratinized cystic lesion. Pathology from FNA biopsy reported scant pancreatic tissue insufficient for a definitive diagnosis. Ultrasonography of the abdomen showed a solid hypodense heterogeneous mass. A CT with contrast confirmed the presence of a 2.0 x 2.2 x 1.7 cm rounded space occupying mass lesion in the pancreatic head. Finally an MRI with contrast showed that the mass was medial to the portal confluence abutting the posterior aspect of the pancreatic head. The findings were suggestive of a splenic artery pseudoaneurysm that might be clotted off. Discussion:- Splenic artery pseudoaneurysm (SAP) is an uncommon finding, with only 157 cases being reported in English-language literature. 77.3% of cases were found in males. Mayo clinic reported 10 cases over 18 years (1980 to 1998). The most common causes of SAP include chronic pancreatitis (46%), abdominal trauma (29%), iatrogenic and postoperative complications (3%), and peptic ulcer disease (2%). Following pancreatitis, SAP can be caused by the leakage of pancreatic enzymes, which eventually leads to necrotizing arteritis and subsequent vessel wall destruction. Pancreatic pseudocyts can occur in conjunction with SAP 41% of cases. The most common symptoms associated with SAP are hematochezia or melena at 26%, hematemesis at 16%, abdominal pain at 29% as well as hemosuccus pancreaticus at 20%. Diagnosis is most commonly made with angiography (52%) followed by CT scan (36%). Since the risk of rupture is high (37%), urgent repair of SAP's is paramount regardless of the size of the SAP.
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