Splenic Artery Pseudoaneurysm Research Articles

A Case Report of Giant Splenic Artery Pseudoaneurysm with Splenic Infarctions

The splenic artery is a frequently affected site for pseudoaneurysms, abnormal bulges in the artery wall. Pseudoaneurysms of the splenic artery are typically linked to pancreatic issues, including acute pancreatitis, chronic pancreatitis, and the formation of pancreatic pseudocysts.[1,2,3,4] These pseudoaneurysms can rupture into nearby organs, leading to gastrointestinal bleeding.[5] Common symptoms associated with splenic artery pseudoaneurysms include the passage of bloody stools (hematochezia) or dark, tarry stools (melena), vomiting blood (hematemesis), abdominal pain, and a condition known as hemosuccus pancreaticus.[6] In the instance of our patient, hematemesis, anaemia, and stomach pain were observed.[6]
 The preferred imaging method for diagnosing splenic artery pseudoaneurysm is CT angiography.[7] Diagnosing a pseudoaneurysm of the splenic artery can be challenging due to its rarity. Still, splenic infarct can provide a valuable diagnostic clue, as was the case similar to our patient.[6]
 Pseudoaneurysm of the splenic artery is a relatively rare complication with associated pancreatitis.[1] While pseudoaneurysms can develop in any blood vessel near the pancreas, the splenic artery is most frequently affected, accounting for about 60% of cases due to its proximity to the pancreas.[8] In autopsy studies, the reported incidence of splenic artery pseudoaneurysms ranges from approximately 0.098% to 10.4%.[9] Identifying this less common vascular complication is crucial because it has the potential to rupture and lead to gastrointestinal bleeding.[5]

An Atypical Triad: Case Report of Giant Splenic Artery Pseudoaneurysm Concomitant with Mononucleosis and Intraductal Papillary Mucinous Neoplasms

An Atypical Triad: Case Report of Giant Splenic Artery Pseudoaneurysm Concomitant with Mononucleosis and Intraductal Papillary Mucinous Neoplasms

Splenic Hilar Involvement and Sinistral Portal Hypertension in Unresectable Pancreatic Tail Cancer.

Pancreatic tail cancer (PTC) frequently displays splenic hilar involvement (SHI), but its impact on clinical outcomes remains unclear. We investigated the clinical impact of SHI in patients with unresectable PTC. We retrospectively reviewed all patients with unresectable PTC who received first-line therapy at our institution from 2016 to 2020. Of the 111 included patients, 48 had SHI at diagnosis. SHI was significantly associated with younger age, liver metastasis, peritoneal dissemination, larger tumor size, modified Glasgow prognostic score of 1 or more, splenic artery involvement, gastric varices, and splenomegaly. Shorter median overall survival (OS; 9.3 vs. 11.6 months, p = 0.003) and progression-free survival (PFS; 4.3 vs. 6.3 months, p = 0.013) were observed in SHI patients. Poor performance status of 1 or 2, tumor size > 50 mm, hepatic metastasis, mGPS of 1 or 2, and SHI (hazard ratio: 1.65, 95% confidence interval: 1.08-2.52, p = 0.020) were independent predictors of shorter OS. Splenic artery pseudoaneurysm rupture and variceal rupture were rare and only observed in cases with SHI. Splenic hilar involvement is associated with worse outcomes in pancreatic tail cancer.

SAT676 Severe Recurrent Pancreatitis In A Familial Partial Lipodystrophy Patient On Metreleptin

Abstract Disclosure: P. Sargin: None. M. Vinicky: None. A. Biglione: None. Lipodystrophy syndromes are congenital or acquired disorders characterized by either total or partial lipoatrophy and often unrecognized by clinicians due to their rarity. Patients with lipodystrophy may demonstrate severe complications of metabolic syndrome since lipids are deposited in non-adipose organs where they induce lipotoxicity resulting in insulin resistance, diabetes mellitus, hypertriglyceridemia, and hepatic steatosis. Familial Partial Lipodystrophy (FPLD) syndromes are one of the four major subtypes of lipodystrophy syndromes. These are heterogeneous, mostly autosomal dominant, and characterized by site-specific subcutaneous adipose tissue loss. The management of patients with FPLD can be challenging with life-threatening complications, heavy dependence on lifestyle modifications, limited treatment options and medication availability. One of the important complications seen in these patients is pancreatitis, related to high triglyceride levels. It can be recurrent and the episodes can be more severe compared to the general patient population. Metreleptin, the human leptin analogue, is the only disease-specific treatment for lipodystrophy syndromes and it has been shown to reduce the complications of leptin deficiency, but it is not currently approved for FPLD in the USA. Previous studies showed improvement of the complications of FPLD with its use. Our case is a 29-year-old woman who has Dunnigan type FPLD with a history of numerous bouts of pancreatitis while on fenofibrate, statin and omega-3-acid ethyl esters, later was on metreleptin for almost 3 years, presented to our hospital with typical symptoms of acute pancreatitis incited by severe hypertriglyceridemia (>1,500 mg/dL). Lipase levels were high at 27,501. Patient was treated with vigorous intravenous hydration, insulin and home metreleptin was continued at the hospital. Despite the initial improvement of the symptoms, on the 6th day of hospitalization, she developed worsening abdominal pain, nausea, and vomiting. CT angiogram of the abdomen showed 2.0 cm splenic artery pseudoaneurysm. Coiled embolization of the superior segmental branch of the splenic artery performed by interventional radiologist which was further complicated by splenic infarction. Her condition improved eventually, she was able to be discharged home. Importance of adherence to medications and special diet was discussed with the patient in length. This case report aims to bring attention to this rare disease and urgent need for further treatment options for these patients to prevent serious complications in this young patient population. Metreleptin is a daily injection which could be challenging to adherence and the consequence can be relapse of pancreatitis. Lack of other treatment options, treatment availability, physician awareness are barriers to optimize the treatment for these complex patients. Presentation: Saturday, June 17, 2023

S2113 Severe Necrotizing Gas Gangrene Pancreatitis with Bacteremia: A Complex Case Report with Septic Shock, Splenic Artery Pseudoaneurysm, and Persistent Necrotic Tissue

S2113 Severe Necrotizing Gas Gangrene Pancreatitis with Bacteremia: A Complex Case Report with Septic Shock, Splenic Artery Pseudoaneurysm, and Persistent Necrotic Tissue

Managing Splenic Artery Pseudoaneurysms-An Experience from a Developing Country. A Retrospective Review.

Objectives: Splenic artery pseudoaneurysm is a rare but potentially fatal condition. Early diagnosis and intervention are the key steps in the management of this condition. We have reviewed our institution's 4-year data regarding the presentation and management of this condition. Methods: We conducted a prospective review of the records of 10 patients who presented to our institute from January 2018 to December 2021 with a splenic artery pseudoaneurysm. We found one patient with a true aneurysm, whom we excluded from the study. Results: This study included seven male and two female patients with a mean age of 47.7 years. Six patients presented to the emergency department with bleeding secondary to rupture aneurysm, which is the most common reason for admission. Pancreatitis was found to be the most common cause for splenic artery pseudoaneurysm (five patients). Computed tomography angiogram remained the modality of choice for diagnosing splenic artery pseudoaneurysm. All patients were successfully managed with endovascular intervention. Conclusion: Splenic artery pseudoaneurysm is usually a rare complication of pancreatitis, which is associated with high morbidity and mortality. Timely diagnosis and intervention are the keys to successful management. Endovascular embolization should be the first-line therapy in splenic artery pseudoaneurysm.

Hemosuccus Pancreaticus Caused by Splenic Artery Pseudoaneurysm: Two Cases Diagnosed and Treated With EUS

Hemosuccus Pancreaticus Caused by Splenic Artery Pseudoaneurysm: Two Cases Diagnosed and Treated With EUS

Rupture of Splenic Artery Pseudoaneurysm with Pancreatitis: A Rare Case Report

Vascular involvement of pancreatic pseudocyst is a rare complication that can potentially result in a fatal outcome. If there is vascular involvement, the splenic artery is most often involved; its rupture and massive bleeding into the peritoneal cavity or retroperitoneal space can lead to hypovolemic shock. We report on a 66-year-old-male patient, who initially presented with atypical chest pain and was diagnosed with a rupture of the splenic artery pseudoaneurysm resulting from chronic pancreatitis. The patient was successfully treated by transcatheter arterial embolization (TAE).The patient’s condition improved and he was finally discharged without complications 22 days after admission. The splenic arterial involvement in the patient with pancreatic pseudocyst is an uncommon complication. Chest pain with pleuritic symptom is often misdiagnosed as cardiovascular or pulmonary disease. Proper management depending on hemodynamic stability can prevent a life-threatening event.

Splenic artery pathology presentation, operative interventions, and outcomes in 88 patients with vascular Ehlers-Danlos syndrome

ObjectiveVascular Ehlers-Danlos syndrome (VEDS) is rare and associated with arteriopathies. The aim of this study is to investigate the presentation, operative interventions, and outcomes of splenic arterial pathology in a population of more than 1500 individuals with genetically confirmed VEDS due to pathogenic COL3A1 variants. MethodsCross-sectional analysis of 1547 individuals was performed. The data were assembled by harmonizing data from three overlapping cohorts with genetically confirmed VEDS: the VEDS Collaborative Natural History Study (N = 242), a single-center cohort (N = 75), and the University of Washington Collagen Diagnostic Lab cohort (N = 1231). Duplicates were identified and removed. Patients were selected for analysis if they had splenic artery aneurysm (SAA), pseudoaneurysm, dissection, thrombosis, or rupture. Demographics, COL3A1 variants, interventions, and outcomes were analyzed. Comparisons by splenic artery rupture were made. ResultsA total of 88 patients presented between 1992 and 2021 with splenic artery pathology (5.7% of the cohort; mean age at diagnosis, 37 ± 11.1 years; 50% male). One-third were diagnosed with VEDS prior to the splenic artery pathology diagnosis, and 17% were diagnosed post-mortem. Most had a positive family history (61%). Most had COL3A1 variants associated with minimal normal collagen production (71.6%). Median follow up was 8.5 years (interquartile range, 0.9-14.7 years). Initial presentation was rupture in 47% of the cases. Splenic artery rupture overall was 51% (n = 45), including four cases of splenic rupture. There were no major differences in VEDS-related manifestations or COL3A1 variant type by rupture status. SAA was noted in 39% of the cases. Only 12 patients had splenic artery diameter documented in 12 cases with a median diameter of 12 mm (interquartile range, 10.3-19.3 mm). A total of 34 patients (38.6%) underwent 40 splenic arterial interventions: 21 open surgical, 18 embolization, and one unknown procedure. More than one splenic artery intervention was performed in five cases (14.7%). Open repair complications included arteriovenous fistula (n = 1), intestinal or pancreatic injury (n = 1 each), and four intraoperative deaths. There were no deaths or access site complications related to splenic artery embolization. Four patients (23.5%) developed a new SAA in the remaining splenic artery post embolization. All-cause mortality was 35% (n = 31), including 22 related to a ruptured splenic artery. ConclusionsSplenic arteriopathy in VEDS is associated with variants that affect the structure and secretion of type III collagen and frequently present with rupture. Rupture and open repair are associated with high morbidity and mortality, whereas embolization is associated with favorable outcomes. Suggest repair considerations at SAA diameter of 15 mm. Long-term follow-up is indicated as secondary splenic arteriopathy can occur.

Severe acute pancreatitis evolving with rupture of a splenic artery pseudoaneurysm in a pediatric patient

Severe acute pancreatitis evolving with rupture of a splenic artery pseudoaneurysm in a pediatric patient

Splenic Artery Pseudoaneurysm, after Spleen Preserving Left Pancreatectomy

Splenic Artery Pseudoaneurysm, after Spleen Preserving Left Pancreatectomy

Splenic Artery Pseudoaneurysm Rupture in Pseudocyst of Pancreas Successfully Managed with Coiling: A Rare Case Report

Abstract Splenic artery pseudoaneurysm is a rare condition with approximately 1% prevalence. Potential risks of splenic artery aneurysms (SAAs) include rupture and life-threatening hemorrhage, which can occur in about 10% of cases. The ratio of splenic artery pseudoaneurysms in female-to-male is 4:1. It is significantly higher in patients older than 60 years and patients with portal hypertension. Such patients are usually asymptomatic, but 20% of them present with complaints such as abdominal pain and chest pain and most are usually diagnosed incidentally. In this case report, we have highlighted a 40-year-old patient who presented with pain abdomen and shock, which, after a thorough workup, came out to be a case of pseudocyst of the pancreas with rupture of SAA as well as eventration into the mediastinum through hiatus hernia. The patient was successfully managed with splenic artery coiling.

Cervical Small Cell Neuroendocrine Carcinoma With Ectopic ACTH Secretion and Acute Pancreatitis

Abstract Ectopic Cushing syndrome from a primary carcinoma of the cervix is an exceedingly rare phenomenon. The objective of this review is to describe our clinical case and summarize the clinical characteristics, investigations, and outcomes of all published cases. We describe a previously healthy 39-year-old woman presenting with abnormal uterine bleeding, leading to a diagnosis of stage IIIC1 small cell neuroendocrine carcinoma of the cervix, human papillomavirus-associated. She was treated with neoadjuvant chemotherapy, radical hysterectomy, adjuvant chemotherapy, and pelvic radiation. Unfortunately, she developed progressive disease with multifocal hepatic metastases and lesions in the para-aortic lymph nodes. Eighteen months after her initial diagnosis, she presented with severe Cushing syndrome and acute pancreatitis and died from a splenic artery pseudoaneurysm. A literature review identified 10 published cases of ectopic ACTH secretion in the setting of carcinoma of the cervix. The mean age of presentation was 40. The majority (70%) occurred in the small cell neuroendocrine variant. In 80% of patients, cushingoid features developed concomitantly or shortly after the discovery of metastatic disease; cushingoid features included new-onset hypertension (30% of patients), hyperglycemia (50%), and hypokalemia (50%). All 10 patients died of the disease with a median survival of 2.5 months (range, 1-10 months) from the time of presentation with Cushing syndrome. Carcinoma of the cervix is a rare cause of ectopic Cushing syndrome. Nevertheless, it should be considered as a source of ectopic ACTH secretion in all women, especially those presenting with gynecologic complaints. Despite surgical resection and systemic therapy, prognosis is poor.

Massive upper gastrointestinal bleeding caused by splenic artery pseudoaneurysm rupture: A case report

Massive upper gastrointestinal bleeding caused by splenic artery pseudoaneurysm rupture: A case report

Massive bleeding from gastric ulcer-induced splenic artery pseudoaneurysm successfully treated with transcatheter arterial embolization and surgery: a case report

BackgroundUpper gastrointestinal bleeding (UGIB) is a routine medical emergency. The most common non-variceal cause is peptic ulcer disease, while a rare presentation is peptic ulcer-induced splenic artery pseudoaneurysm (SAP). Primary endoscopic treatment is generally attempted for UGIB; however, it sometimes fails when arterial etiology is present. In such cases, either transcatheter arterial embolization (TAE) or surgery is necessary, but the choice of treatment is controversial. We present a case that illustrates the utility of both approaches in a gastric ulcer-induced SAP.Case presentationA 33-year-old male presented with hemorrhagic shock secondary to UGIB. The source of bleeding was identified as an SAP that was caused by a gastric ulcer. TAE enabled temporary bleeding control despite the patient’s poor overall condition and limited blood transfusion capability. However, rebleeding occurred soon after stabilization. Ultimately, we performed proximal gastrectomy and splenic artery ligation, and the patient survived.ConclusionsSAP is an uncommon occurrence, and angiographic information is important for correctly identifying the source of bleeding. The treatment for SAP bleeding is basically the same as for endoscopically unmanageable non-variceal UGIB, since TAE and surgery each have a different utility, depending on the situation. If surgery is performed, especially SA ligation and gastrectomy, it is important to consider the circulation of the spleen and residual stomach. Using TAE and laparotomy, we managed to save the life of the patient with massive hemorrhage under limited circumstances.

S2991 Fontan Liver Disease Associated Splenic Aneurysms

Introduction: The Fontan procedure results in liver fibrosis in all recipients and can result in many disastrous complications. Here we present a patient with hemoperitoneum from a splenic artery pseudoaneurysm. Case Description/Methods: A 25 year old female with a history of a hypoplastic left heart status post Fontan Procedure, Atrial Flutter on rivaroxaban, cirrhosis complicated by downhill varices presented to the hospital with diffuse crampy abdominal pain. She initially attributed her symptoms to constipation, however her symptoms did not resolve after she took stool softeners which resulted in a bowel movement. Patient underwent a CT Abdomen Pelvis at an outside hospital which showed a 5.9 cm left cystic ovarian mass with concern for active hemorrhage due to surrounding fluid. On transfer, she underwent a CT Angiogram of the Abdomen and Pelvis which was notable for increased hemoperitoneum and as well as a “3.5 cm pseudoaneurysm arising from the proximal aspect of the splenic artery.” This was thought to be the source of the hemoperitoneum. Patient subsequently underwent embolization of the mid splenic artery with a 10mm amplatzer plug, embolization of the splenic artery aneurysm with concerto detachable coils and embolization of the proximal splenic artery with a 12mm amplatzer plug. (Figure) Discussion: Patient’s who have undergone the Fontan procedure have universal development of liver fibrosis. Splenic artery pseudoaneurysms are an extremely rare entity and are typically associated with chronic pancreatitis, although can be associated with trauma, post-operative complications and peptic ulcer disease. Fontan associated liver disease has been reported to be associated with splenic artery aneurysms in only one other case report. This can be a potentially fatal complication.Figure 1.: CTA with Splenic Artery Pseudoaneurysm.

S2659 Splenic Artery Pseudoaneurysm as a Rare Cause of Upper Gastrointestinal Bleeding

Introduction: Upper gastrointestinal bleeding (UGIB) is one of the most common causes for hospital admission in the US. Common etiologies for UGIB include peptic ulcer disease, erosive esophagitis, varices, and less commonly malignancies. Splenic artery pseudoaneurysm (PSA) is a known complication of pancreatitis. It may be asymptomatic or present with left upper quadrant or epigastric pain, and rarely as hemorrhagic shock. Splenic artery PSA presenting with UGIB is extremely unusual. Case Description/Methods: We present the case of a 57-year-old male with alcohol use disorder complicated by a prior episode of alcoholic pancreatitis, who presented with 3 days of hematemesis, melena, and recurrent syncopal episodes. In the ED his vitals and physical exam were notable for tachycardia, hypotension, and melena. Labs revealed a hemoglobin of 4.2. Non-contrast CT of the abdomen and pelvis showed evidence of blood in the antrum and a 2.0 x 1.6 cm out-pouching from the greater curvature of the stomach which was postulated to be a gastric diverticulum (image 1). Upper endoscopy revealed fresh blood in the antrum and duodenum, as well as a massive adherent clot in the fundus. Since no single site of active bleeding was identified, the patient was started on IV PPI with continued close monitoring in the ICU. He continued to have melena, and increased PRBC requirements. Repeat EGD was performed but was unchanged from prior. A CT angiogram of the abdomen and pelvis demonstrated a 1.5 cm actively bleeding PSA arising from a first divisional branch of the splenic artery communicating with the fundus of the stomach (images 2 & 3). The patient underwent successful coil embolization (image 4). Hemoglobin remained stable throughout the remainder of his admission with no further evidence of bleeding. Discussion: This case demonstrates PSA as a rare cause of UGIB. Lesions are most commonly caused by chronic pancreatitis, pancreaticobiliary surgery, and trauma. This patient’s PSA was likely secondary to his prior episode of alcoholic pancreatitis. Prompt diagnosis of PSA is essential given the high mortality rate associated with rupture. Clinicians should maintain a high index of suspicion for gastrointestinal PSA in patients with a history of pancreatitis who present with UGIB for whom no obvious source of bleeding can be identified on endoscopy.Figure 1.: CT Thx/Abd/Pel demonstrating a 2.0 x 1.6 cm out-pouching from the greater curvature of the stomach (arrow), postulated to be a gastric diverticulum, 2. CT Angiogram Abd/Pel demonstrating the splenic artery PSA (arrow), 3. Fluoroscopic imaging re-demonstrating the splenic artery PSA with extravasation of contrast into the gastric lumen, 4. Splenic Artery PSA after successful coil embolization.

S1743 Hemosuccus Pancreaticus or Just a Bunch of Hocus Pocus

Introduction: Hemosuccus pancreaticus (HP) is a rare phenomenon defined as bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater. Many potential causes for HP exist, including pancreatic inflammation, arterial aneurysms, and bariatric surgery. A high degree of clinical suspicion and a multidisciplinary approach is key for early diagnosis and treatment. Case Description/Methods: 50-year-old female with a history of RYGB, cholecystectomy, pancreatitis, and iron deficiency anemia, was admitted to the intensive care unit after presenting with maroon stools, abdominal pain, and fatigue with a hemoglobin of 4.8. Within the prior 5 months, she had multiple admissions for abdominal pain and GIB and was diagnosed with alcohol-induced pancreatitis, diverticular bleed, anastomotic erosions, peptic ulcer disease, and a Dieulafoy lesion on numerous EGD/colonoscopies. EGD/enteroscopy performed during this admission revealed old blood in the stomach, without active or old blood in the roux or biliopancreatic limbs. Her colonoscopy showed dark tarry stool throughout. Over the subsequent few days, she required a total of 11 units of packed RBCs. Multiple imaging modalities including computed tomography angiography (CTA) and Meckel's diverticulum scan were negative. She experienced worsening abdominal pain, hematochezia and hematemesis, and required emergent intubation. EGD/enteroscopy was performed and revealed fresh blood at the jejuno-jejunal anastomosis, the roux and biliopancreatic limbs, and active bleeding at the ampulla, consistent with HP (Figure). Interventional Radiology was contacted immediately, and repeat angiography revealed a 6mm splenic artery pseudoaneurysm. A covered stent was placed, and our patient’s hemoglobin remained stable during the rest of her hospitalization, without further episodes of bleeding or abdominal pain. Discussion: HP is an obscure, and potentially life-threatening cause of GIB that is important to include in the differential diagnosis. The classic triad includes sporadic bleeding (upper and lower GIB), intermittent abdominal pain, and hyperamylasemia. There appears to be a significant association between HP and pancreatic inflammation, which our patient had. Additionally, our patient’s RYGB anatomy made the ampulla more challenging to reach, delaying the diagnosis. In addition to IR and surgery, advanced endoscopy has presented novel therapeutic options with endoscopic ultrasound, lumen apposing metal stents and fibrin glue/histoacryl adhesives.Figure 1.: Enteroscopy imaging showing evidence of brisk bleeding from the ampulla of Vater, consistent with hemosuccus pancreaticus.

S2839 Gastrointestinal Bleeding Secondary to Splenic Artery Aneurysm: A Delayed Complication of a Lumen Apposing Metal Stent

Introduction: Lumen apposing metal stents (LAMS) have been widely used for drainage of peri-pancreatic collections. Pseudoaneurysm formation and rupture is an uncommon complication of LAMS. A possible mechanism for bleeding with current LAMS is its bi-flanged design which does not allow mobility of walls or the stent when the size of collection reduces in size post drainage. This can theoretically cause tension over the wall and surrounding vasculature which lead to pseudoaneurysm formation and bleeding. Case Description/Methods: A 71-year-old female with a history of necrotizing pancreatitis complicated by splenic vein thrombosis on warfarin underwent LAMS placement with a significant reduction in the peri-pancreatic collection on follow up imaging. Three months later, she presented with two days of melena and hematochezia. On evaluation, she was hypotensive and tachycardic. Lab work revealed hemoglobin of 6.1 g/dl from a baseline of 12 g/dl. A computerized tomography angiography (CTA) which did not show active GI bleeding. EGD showed a large pulsating non-bleeding vessel within LAMS. Due to the potential of increasing bleeding with the removal of LAMS, a mesenteric angiogram was done demonstrating a splenic artery pseudoaneurysm, and this was successfully embolized with coils. She subsequently underwent repeat EGD following the coiling with successful removal of LAMS. No further bleeding followed stent removal. Discussion: A ruptured pseudoaneurysm can present with abdominal pain, signs of GI bleeding, or hemobilia. CTA is an important (Figure) diagnostic step but can be unremarkable such as in this case. Pseudoaneurysm formation can be prevented with timely removal of LAMS after the successful drainage and reduction in the size of the pancreatic collection Empiric embolization before removal of LAMS can prevent life-threatening bleeding, and therefore discussion with the interventional radiologist should be done before attempting removal of LAMS in such high-risk cases. Although GI bleeding secondary to rupture pseudoaneurysm with LAMS is a rare complication, it should be considered in patients with recent LAMS placement who present with GI bleeding.Figure 1.: Digital subtraction angiogram of the Celiac artery demonstrating luminal irregularity and dilation, consistent with pseudoaneurysm of the main Splenic artery, about the inferior margin of the AXIOS stent.

S1879 A Diagnostically Challenging Case of Primary Pancreatic Lymphoma

Introduction: Primary Pancreatic Lymphoma (PPL) is the exceedingly rare instance of extranodal Non-Hodgkin's Lymphoma developing mainly in the pancreas. We report a diagnostically challenging case of a patient presenting with a rapidly growing pancreatic mass, found to have PPL. Case Description/Methods: A 48-year-old female with past history of tobacco use presented with several months of cramping abdominal pain following COVID-19 infection. She denied weight loss, fevers, or night sweats. Her physical exam, CBC, CMP, lipase, LDH, and CA 19-9 were unremarkable. An abdominal ultrasound revealed a 2.8 x 1.9 x 3 cm cystic mass of the pancreatic head, most congruent with a pseudocyst. Worsening abdominal pain prompted repeat ultrasound one month later, which showed a doubling in size. Endoscopic ultrasound (EUS) with fine needle aspiration of the cystic mass and surrounding lymph nodes yielded cystic contents and reactive lymphadenopathy. Two months later, her abdominal pain worsened and repeat imaging showed further doubling in size with encasement of the celiac plexus. A second FNA performed via EUS redemonstrated cystic contents. An ultrasound-guided core needle biopsy of the mass revealed necrotic CD30+ diffuse large B cell lymphoma (DLBCL). PET scan was suggestive of stage IV PPL (Figure). Imaging also identified an inguinal lymph node that returned as CD10+ BCL6+ high grade follicular lymphoma, which was thought to be a distinct lesion. She was started on R-CHOP. Her clinical course was complicated by the formation and subsequent rupture of a splenic artery pseudoaneurysm, gastrointestinal bleeding, anuric kidney injury, and intestinal ischemia. She ultimately transitioned to comfort care. Discussion: Primary pancreatic lymphoma comprises 0.6% of extranodal lymphomas and 0.2% of primary pancreatic tumors. The clinical presentation is often vague and includes abdominal pain, B symptoms, jaundice, or bowel obstruction. The diagnostic criteria according to the WHO requires that the (1) majority of tumor burden be localized to the pancreas and (2) existing nearby and distant lymph node involvement should be secondary to pancreatic presentation. A biopsy is required to diagnose PPL, which is histologically most often DLBCL. Our case highlights the challenges associated with diagnosing PPL despite two EUS with FNA. Although rare, one should proceed with a high index of suspicion for PPL in any patient presenting with a rapidly enlarging pancreatic mass.Figure 1.: CT image of necrotic pancreatic mass.