Pancreatic Pseudoaneurysm Research Articles

A Case of Pancreatic Pseudoaneurysm

Pancreatic pseudoaneurysm (PSA) is a rare complication of chronic pancreatitis. Diagnosis requires high index of suspicion and urgent intervention is required once diagnosed as delayed treatment leads to poor outcomes and mortality. In this report, we discuss the case of a 30 year old male with a history of chronic pancreatitis who presented with upper gastrointestinal bleed (UGIB). Physical exam was elevated blood pressure, tachycardia and epigastric tenderness. A CT angiogram of abdomen done revealed pseudoaneurysm of pancreas. Patient emergently underwent endovascular embolization and coiling with resolution of GI bleed post procedure.

Percutaneous computed tomography-guided glue embolization of a pancreatic pseudoaneurysm with underlying occluded celiac and superior mesenteric artery.

Percutaneous computed tomography-guided glue embolization of a pancreatic pseudoaneurysm with underlying occluded celiac and superior mesenteric artery.

Pancreatic pseudoaneurysm mimicking pancreatic tumor: A case report and review of literature

BACKGROUND Pancreatic pseudoaneurysm is a rare vascular complication of chronic pancreatitis (CP) or necrotizing pancreatitis with an incidence of 4% to 17%, but it is potentially life-threatening. It is well known that most pancreatic pseudoaneurysms are clinically associated with pancreatic pseudocysts and are usually in the peripancreatic body-tail. A minority of intrapancreatic pseudoaneurysms occur in the absence of pseudocyst formation. Noninvasive computed tomography (CT) and magnetic resonance imaging (MRI) are most commonly used examinations for screening pancreatic pseudoaneurysms. Notably, the rare intrapancreatic pseudoaneurysm in the pancreatic head can mimic a hypervascular solid mass and be misdiagnosed as a pancreatic tumor. CASE SUMMARY We report the case of a 67-year-old man who had been admitted to our hospital due to recurrent abdominal pain for 1 mo that was aggravated for 5 d. CT and MRI revealed a mass in the pancreatic head with significant expansion of the main pancreatic duct and mild atrophy of the pancreatic body-tail. He was admitted to the department of hepatobiliary and pancreatic surgery due to the possibility of a pancreatic tumor. The patient was then referred for endoscopic ultrasonography (EUS) with possible EUS-FNA. However, EUS showed a cystic lesion in the pancreatic head with wall thickness and enhancing nodules, which was doubtful because it was inconsistent with the imaging findings. Subsequently, color doppler flow imaging demonstrated turbulent arterial blood flow in the cystic lesion and connection with the surrounding vessel. Therefore, we highly suspected the possibility of CP complicated with intrapancreatic pseudoaneurysm, combined with the patient's long-term drinking history and the sonographic features of CP. Indeed, angiography revealed an oval area of contrast medium extravasation (size: 1.0 cm × 1.5 cm) at the far-end branch of the superior pancreaticoduodenal artery, and angiographic embolization was given immediately at the same time. CONCLUSION EUS is an important differential diagnostic tool when pancreatic pseudoaneurysm mimics the imaging appearance of a hypervascular pancreatic tumor.

Pseudoaneurysmal Rupture Associated with Pancreatitis Treated with Transarterial Embolization: A Case Series

Pancreatic pseudoaneurysm is a potentially life-threatening complication often associated with pancreatitis or pancreatic surgery. As the rupture of pancreatic pseudoaneurysms can lead to catastrophic bleeding and is associated with high mortality rates, clinical suspicion and early diagnosis are essential to improve patient outcomes. In the management of pseudoaneurysms, transarterial embolization (TAE) could be effective; however, there have been limited local studies on the outcomes of TAE for patients with pseudoaneurysm rupture associated with pancreatitis. Here, we describe patients who were diagnosed with pseudoaneruysm rupture associated with pancreatitis and treated with TAE.

Persistent Bleeding after Coil Embolization of a Pancreatic Transplant Pseudoaneurysm: Should Covered Stents Be the Primary Management?

Life-threatening arterial complications after pancreatic transplantation can be dire. Pseudoaneurysms can be challenging to treat. There are multiple strategies to treat such complications. We present a case of pancreatic pseudoaneurysm which was initially treated by coiling followed by subsequent covered stent placement for a more durable outcome. We advocate for a "stent first" approach to these lesions if feasible.

Gastrointestinal bleeding caused by rupture of a posterior inferior pancreaticoduodenal artery pseudoaneurysm: A case report

Gastrointestinal bleeding caused by a ruptured pancreatic pseudoaneurysm is rare, and a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery is especially rare. A 68-year-old man was hospitalized after presenting intermittent black stools and dyspnea accompanied by severe anemia. Angiographic examination revealed that Pseudoaneurysm of the posterior inferior pancreaticoduodenal artery. Angiography was performed and revealed a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery. Subsequently, a blood transfusion and endovascular embolization were performed. The patient's gastrointestinal bleeding stopped, and the hemoglobin level remained stable. During 1 year of follow-up, the patient remained in a generally good condition. posterior inferior pancreaticoduodenal artery pseudoaneurysmIt is rare and difficult to diagnose, gastrointestinal bleeding is a serious complication, vascular interventional embolization is effective.

A rare case of severe anaemia due to pancreatic pseudoaneurysm complicated by COVID-19

Pancreatitis in children is now diagnosed more frequently with an incidence of acute pancreatitis turning to chronic being 20–25%. Pancreatic pseudoaneurysm is a rare and life-threatening complication of chronic pancreatitis. An adolescent a known case of chronic pancreatitis for 3 years, presented with a history of recurrent black-coloured stools for 1 month and haematemesis, fever and cough for 2 days. The child was pale and febrile with tachypnoea and tachycardia with severe tenderness in the epigastric and umbilical regions. Investigations showed severe anaemia (Hb-1.4 g/dL) with positive COVID-19 Reverse transcription-polymerase chain reaction. Computed tomography abdomen showed pancreatitis with a pseudocyst, pseudoaneurysm from the gastroduodenal artery and consolidation in lung COVID 19 Reporting and data system. The child was treated symptomatically along with multiple packed red blood cells transfusions. Selective catheterisation and stent grafting of the gastroduodenal artery was performed. This case report highlights an unusual complication of pancreatitis with concurrent COVID infection.

S1693 Incidental Pancreatic Pseudoaneurysm Following ERCP

Introduction: ERCP is a commonly performed procedure, with up to 500,000 ERCPs performed annually. Commonly known complications include infection, pancreatitis, hemorrhage and perforation. Here we describe a case of pancreatic pseudoaneurysm (PDA) which resulted from Post-ERCP pancreatitis. Case Description/Methods: An 84-year-old female presented to hospital with vomiting, epigastric pain and increased weakness for one week after undergoing ERCP with stone removal and stent placement. On presentation, she was hemodynamically stable. Hepatic and pancreatic enzymes were within range, hemoglobin and hematocrit were stable, 12.6g/dL and 37.1%, respectively, and near patient’s baseline (13g/dL). CT Abdomen with IV contrast showed a 9mm hyperattenuating PDA in/adjacent to pancreatic head (which was new from recent MRCP). For better characterization, a CT angiogram with pancreatic protocol was performed, which redemonstrated stable 9mm PDA (Figure). Given no evidence of bleeding and improved clinical condition of the patient, no intervention was indicated, and the patient was discharged home. Discussion: Post-ERCP pancreatitis has an annual incidence of around 14%. Post-procedure pancreatic PDA is rarer still, seen in around 10% of the patients with post-ERCP pancreatitis. Irritation of arterial and ductal walls by indwelling catheter can lead to the development of both pancreatitis and PDA. Most of the previously reported cases of post-ERCP PDA were seen in sickle cell disease patients [1, 2]. Our patient is unique as she did not have sickle cell disease and did not have pancreatitis on arrival as per revised Atlanta criteria. We suspect patient developed pancreatitis prior to arrival to ED as she was symptomatic for one week after ERCP. A bleeding PDA is an emergency with high morbidity and mortality, so prompt diagnosis and treatment is imperative to prevent further complications.Figure 1.: Small 9 mm focus of enhancement at the pancreatic head concerning for pseudoaneurysm

S1889 A Case of Ruptured Gastroduodenal Artery Pseudoaneurysms in a Patient With Chronic Pancreatitis

Introduction: Pancreatic pseudoaneurysm is a rare vascular complication of pancreatitis, with an estimated prevalence of 10%. Pseudoaneurysm can result from trauma, inflammation, infection, and iatrogenic causes. Due to its weak structural support, the risk of rupture is higher for pseudoaneurysm than that of a true aneurysm of similar size. Pancreatic pseudoaneurysms can lead to life-threatening complications such as rupture and bleeding, with increased morbidity and mortality up to 90% in untreated patients and 12.5% despite treatment. Due to its high mortality rate with rupture, pseudoaneurysms should be treated immediately once it is identified, regardless of their size or whether it is symptomatic or not Case Description/Methods: We present a case of a 68-year-old male patient with a past medical history significant for chronic pancreatitis who presented with altered mental status and hypovolemic shock secondary to unexplained gastrointestinal and retroperitoneal hemorrhage (Table). Computed tomography (CT) Angiography was done which showed an enlarging retroperitoneal and right-sided intraperitoneal hematoma with suspicion for active arterial extravasation or punctate pseudoaneurysms in the pancreatic head (Figure). Celiac angiogram was done under fluoroscopic guidance, which showed gastroduodenal and superior pancreaticoduodenal artery pseudoaneurysms. He underwent successful endovascular coil embolization of the gastroduodenal artery. Post procedure he was monitored in intensive care unit. His clinical condition continued to improve and was discharged to a skilled nursing facility in stable condition. Discussion: Physicians should be aware of pancreatic pseudoaneurysms as rare vascular complication associated with chronic pancreatitis that may lead to fatal gastrointestinal or retroperitoneal bleeding with a high mortality rate. Our case highlights the importance of early diagnosis and prompt treatment in these patients.Figure 1.: A: CT abdomen and pelvis without intravenous contrast showing peripancreatic inflammation surrounding the pancreatic body and head along with retroperitoneal bleed (red arrow). Pancreatic calcifications present (yellow arrow) signifying radiologic evidence of chronic pancreatitis B: CT Angiography showing retroperitoneal and right-sided intraperitoneal hematoma with active arterial extravasation or punctate pseudoaneurysms in the pancreatic head. Table 1. - Laboratory Investigation Investigation Day 1 of Hospitalization Day 5 At Time of Discharge Reference Range White Blood Cell count 24.3 14.3 k/uL 7 k/uL 4.8-10.8 k/uL Red Blood Cell Count 4.77 2.69 MIL/uL 3.19 MIL/uL 4.50-5.90 MIL/uL Hemoglobin 15.8 8.5 mg/dl 10.2 mg/dl 12.0-16.0 g/dL Hematocrit 47.6 25.7 % 30.5% 42-51 % Platelet count 171 155 k/uL 215 k/uL 150-400 k/uL Sodium, Serum 132 139 mEq/L 140 mEq/L 135-145 mEq/L Potassium, Serum 3.0 3.2 mEq/L 3.9 mEq/L 3.5-5.0 mEq/L Blood Urea Nitrogen, Serum 41 17 mg/ml 10 mg/ml 8-26 mg/dL Creatinine, Serum 1.2 0.5 mg/dl 0.6 mg/dl 0.5-1.5 mg/dL Bilirubin, Serum total 0.5 0.7 mg/dl 0.3 mg/dl 0.2-1.1 mg/dL Serum Direct Bilirubin 0.3 0.3 mg/dl < 0.2 mg/dl 0.0-0.3 mg/dL Alkaline Phosphatase 51 48 units/L 73 units/L 56-155 unit/L Aspartate Transaminase 125 21 units/L 18 units/L 9-48 unit/L Alanine Aminotransferase 81 30 units /L 12 units /L 5-40 unit/L Lactic acid Level 8.2 0.8 mmoles/L 1.1 mmoles/L 0.5-1.6 mmoles/L Prothrombin Time 15.2 13.9 sec 10.5 sec 9.9-13.3 seconds International Normalized Ratio 1.31 1.20 0.92 0.85-1.14 Serum Calcium 6.6mg/dl 7.6 mg/dl 9.2 3 mg/dl 8.5-10.5 mg/dl Serum Lipase 24 U/L < =61U/L Serum Triglyceride 163mg/gl 55-150 mg/dl Serum Ethanol < 10 < = 10mg/dl Urine Toxicology Cocaine and methadone Negative

S1758 Mesenteric Vasculitis Presenting as a Pancreatic Pseudoaneurysm Originating From the Superior Mesenteric Artery

S1758 Mesenteric Vasculitis Presenting as a Pancreatic Pseudoaneurysm Originating From the Superior Mesenteric Artery

S2682 A Complicated Course of Pancreatic Pseudoaneurysm Presenting as Hemosuccus Pancreaticus

S2682 A Complicated Course of Pancreatic Pseudoaneurysm Presenting as Hemosuccus Pancreaticus

Hemosuccus Pancreaticus: A Case of Upper Gastrointestinal Bleeding Arising from a Pancreatic Pseudoaneurysm

Pancreatic pseudoaneurysms are possible complications of chronic pancreatitis. These may present as hemosuccus pancreaticus, a rare cause of upper gastrointestinal tract bleeding where a pseudoaneurysm erodes into an adjacent pseudocyst or pancreatic duct, manifesting as bleeding through the pancreatic duct into the duodenal papilla. We report a case of a 32-year-old male with a history of chronic pancreatitis presenting as intermittent upper gastrointestinal tract bleeding secondary to hemosuccus pancreaticus from a pancreatic pseudoaneurysm. The patient underwent multiple sessions of endovascular embolization, which successfully controlled the bleeding despite some failed attempts; thus, a potentially morbid last-resort surgery was avoided.

Management of non-variceal upper gastrointestinal bleeding: role of endoscopic ultrasound-guided treatments.

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common type of upper gastrointestinal emergency with high risk of life-threatening conditions. Nowadays some standard guidelines for the treatments of NVUGIB have been established based on endoscopic therapies, including injection of glues or sclerosing agents, coiling, band ligation, and thermal therapies. Nevertheless, some patients are refractory to standard endoscopic treatments. We have noticed that endoscopic ultrasound (EUS)–guided treatments have been performed by some endoscopists in certain conditions. This review aims to evaluate the role of EUS-guided treatments in the management of NVUGIB. We performed a MEDLINE/PubMed search, and relevant studies were extracted and examined. According to the existing literature, the most common lesions were Dieulafoy’s lesion, pancreatic pseudoaneurysms, and gastrointestinal stromal tumors. EUS-guided treatments mainly include injection, mechanical therapies, and combined therapies, and seem to be a promising technique in the management of NVUGIB, especially for refractory bleeding.

PANCREATIC PSEUDOANEURYSM – A CASE REPORT

Pancreatic pseudoaneurysm is a rare and a major complication of pancreatitis which is associated with significantly high morbidity and mortality. It is due to the weakening of the vessel wall caused by the enzymatic action by the peripancreatic fluid. The most common cause is pancreatitis with pseudocyst formation. Other infrequent causes may include biliopancreatic surgeries, anastomotic leak and trauma. Splenic artery is most commonly involved due to its close proximity to the pancreas. Patient may be asymptomatic or present with bleeding complication or pain abdomen. If left untreated, it may be fatal. We present a case of a 21-year-old female with a pancreatic pseudoaneurysm of splenic artery who was managed surgically for the same.

Pancreatic pseudoaneurysm and its conundrum

Rupture of visceral artery pseudoaneurysm can lead to hypovolemic shock in a patient with pancreatitis. With the advent of minimally invasive treatment techniques most of these can be managed by minimally invasive route and have excellent prognosis when timely intervention is initiated. Herewith, we reported a case of ruptured pseudoaneurysm of superior pancreaticoduodenal artery in a patient with pancreatitis who presented with haematemesis. The patient was successfully managed with coil embolization. A brief case report with review of literature is presented here.

Visceral pseudoaneurysms and the role of endovascular treatment – a case report

Introduction: Visceral pseudoaneurysms are pathological dilations of the visceral arteries and/or their branches. They are a rare entity but with devastating consequences given their high potential for rupture and hemorrhage. The evolution of endovascular techniques has changed the paradigm in the treatment of this entity, making it the preferred option for the elective treatment of visceral pseudoaneurysms. Clinical case: The authors described the case of a pancreatic pseudoaneurysm in a young male patient, with past medical history of chronic pancreatitis and pancreatic pseudocyst, marked smoking and alcoholic habits, which presented with an abdominal pain and a drop in hemoglobin. After discussing the case with the Vascular Surgery department, it was decided towards an endovascular treatment given the patient's clinical stability and appropriate anatomical location for the proposed intervention. Coil embolization via humeral artery was performed with immediate angiographic success, and clinical, analytical and imaging improvement in the postoperative period. Conclusion: In addition to open surgical repair and laparoscopic surgery, there are also endovascular procedures for the treatment of visceral pseudoaneurysms, so the vascular surgeon must be aware with the available strategies, taking into account the patient, the characteristics and location of the visceral pseudoaneurysm.

Hemosuccus Pancreaticus Following Acute Pancreatitis in a 12-years-old Boy Secondary to Pancreatic Pseudoaneurysm Treated With Endovascular Coil Embolization

Hemosuccus pancreaticus is a very rare cause of upper gastrointestinal bleeding in children. It is defined as bleeding from the pancreatic or peripancreatic vessels into the main pancreatic duct and may be life-threatening. We present the case of a 12-year-old boy with hematemesis and severe anemia that developed following an episode of acute pancreatitis. Upper endoscopy did not reveal a bleeding source. An endoscopic retrograde cholangiopancreatography performed for the evaluation of common bile duct obstruction identified bleeding from the pancreatic duct. Subsequently, the bleeding source, a pseudoaneurysm of the splenic artery, was identified by conventional angiography and occluded with coil embolization. The diagnosis of hemosuccus pancreaticus may be difficult in children due to rare occurrence and the unusual anatomical site; hence, a high index of suspicion is needed in a patient with a history of pancreatitis who presents with intermittent upper gastrointestinal bleeding and normal upper endoscopy.

S3476 Workup of a Suspected Pancreaticopleural Fistula in a Young Male

Introduction: Pancreatic fistulas are an abnormal connection between the pancreas and an adjacent or distant structure or organ. These can be characterized as internal or external depending if the pancreatic duct communicates with the skin or not. The most common cause of an internal pancreatic fistula is pancreatitis associated with chronic alcohol. Pancreatopleural fistulas develop by leakage of pancreatic exocrine secretions through the openings in the diaphragm. Here we present a case, where there was concern for a pancreatopleural fistula. Case Description/Methods: A 31-year-old male with past medical history of chronic recurrent pancreatitis complicated by enlarging pseudocysts and portal vein thrombosis was transferred to our facility from outside hospital for hemorrhagic pancreatic pseudoaneurysm status post IR embolization. He had been bleeding from the hemorrhagic pseudoaneurysm at the previous hospital and had been treated with an initial IR embolization procedure for this 4-5 days before arriving at our facility. He underwent repeat IR embolization procedure with repositioning of the malpositioned coil 6 days after admission and subsequently underwent EGD with endoscopic ultrasound and cysgastrectomy for treatment of his associated pancreatic pseudocyst 12 days after admission. Pleural effusion seen on Xray was thought to be secondary to pancreatic fluid accumulation. Thoracentesis was subsequently performed due to patient complaints of dyspnea and analysis showed > 12,000U/L of amylase and black fluid concerning for a pancreatic pleural fistula (Figure A). Patient had a repeat X-ray the following day with accumulation of the pleural effusion (Figure B). Patient was started on TPN and Octreotide for treatment. Repeat thoracentesis yielded amber colored fluid and a CT chest, abdomen and pelvis did not show evidence of fistula formation. It was determined that the initial thoracentesis performed on the patient was actually placed into the pancreatic pseudocyst due to severe elevation of the hemidiaphragm. The patient was ultimately discharged with plans to follow-up with general surgery as an outpatient for possible pancreatectomy. Discussion: We believe that our findings during the care of this patient are important for Gastroenterologists as they provide an excellent opportunity to review both the common and obscure complications of pancreatitis. entity that can occur in patients with acute pancreatitis and is characterized by small, left sided pleural effusions.Figure 1.: Figure A. Thoracentesis fluid obtained from patient concerning for a pancreatic pleural fistula. Figure B. Repeat chest x-ray showing re-accumulation of large left-sided pleural effusion.

Abstract No. 125 Endovascular versus percutaneous treatment of pancreatic pseudoaneurysms

To compare outcomes after endovascular versus percutaneous treatment of pancreatic pseudoaneurysms The research subjects review board approved this retrospective cohort study. Angiograms performed between June 2013 through June 2019 were evaluated. In patients who underwent visceral angiography, a subset of patients with suspected pancreatic pseudoaneurysms were identified. Multiple factors were evaluated including age, hemodynamic status, grade of injury, initial imaging result, angiographic result, vessel embolized, embolic agent used, technical outcome and complication rates in the following 90 days. 17 unique visceral artery pseudoaneurysms were identified in 16 patients (7F). 16 pseudoaneurysms were secondary to chronic pancreatitis and one pseudoaneurysm was secondary to an abscess adjacent to the pancreatic tail after splenectomy. Six patients were treated with endovascular embolization. Four patients were treated with percutaneous embolization, of which three were treated with thrombin and one with a 50/50 mixture of n-BCA/lipiodol. Seven patients underwent no embolization. Technical success was 100% for both embolization techniques. When comparing endovascular versus percutaneous embolization there was no difference in average age (57.2 ± 13.9 years vs 53 ± 13.4 years) or volume of the active core measured on prior CT (30.6 mL ± 27.8cc vs 30 mL ± 30.2 cc). One of the patients in the percutaneous group had rebleeding, which was treated successfully with endovascular coiling. No patients treated with endovascular embolization had rebleeding. One patient treated with percutaneous embolization died 22 days after embolization due to respiratory failure. One patient died 13 days after endovascular embolization of uncertain etiology. Overall, mortality among treated patients was 20%. Mortality rate after interventional radiology treatment of pancreatic pseudoaneurysms was 20% in treated patients. This is lower than prior reported studies. Post treatment rate of rebleeding was 10% and did not result in increased mortality. Percutaneous treatment of pancreatic pseudoaneurysms had a higher rate of mortality and rebleeding than endovascular treatment.

Treatment of mycotic superior mesenteric vein pseudoaneurysm via placement of covered endovascular stent.

Vascular pseudoaneurysms are a rare yet life-threatening complication of untreated pancreatic pseudocysts related to their high risk of rupture and bleeding. Several studies and reports have established endovascular approaches as a successful first-line therapy in the management of arterial pancreatic pseudoaneurysms. However, no reports have been published describing endovascular repair of a venous pseudoaneurysm that developed after infection of a chronically stable pancreatic pseudocyst, most likely due to its rare occurrence. We report in this technical note the treatment of a superior mesenteric vein pseudoaneurysm that developed as a result of an infected small pancreatic pseudocyst, by radiologic placement of a covered endovascular stent.