Complication of Pancreatic Pseudocyst: Splenic Artery Pseudoaneurysm Bleeding on The Basis of Cystogastrostomy

Yıl 2023, Cilt: 10 Sayı: 2, 129 - 133, 21.08.2023

Hüseyin Kılavuz , Çağrı Erdim , Murat Demir , Ece Batur , İdris Kurtuluş

https://doi.org/10.47572/muskutd.1122675

Öz

We aimed to present our case who presented with upper gastrointestinal bleeding findings due to splenic artery pseudoaneurysm, a rare complication of pancreatic pseudocyst. A 67-year-old male patient with a history of chronic pancreatitis surgery and gastrojejunostomy surgery and endoscopic cystogastrostomy due to a pancreatic pseudocyst that developed 6 months after this surgery was admitted to our emergency department with the findings of upper gastrointestinal bleeding. In the radiological evaluation, it was determined that the splenic artery pseudoanerism ruptured to the cystogastrostomy line and caused bleeding. In the invasive angiography performed by the interventional radiology clinic, coil embolization was performed for the splenic artery pseudoaneurysm and the eroded gastroduodenal artery. After the procedure, active bleeding stopped in control gastroscopy, and additional blood product replacement was not needed in the follow-ups. The patient, who developed ventilator pneumonia and catheter sepsis during the intensive care follow-up, died on the 10th day after the procedure due to severe sepsis. Computed tomographic angiographic evaluation should be performed in addition to endoscopic interventions in patients with previous pancreatic surgery and a history of pancreatic pseudocyst presenting with signs of gastrointestinal bleeding. Pancreatic pseudocyst can cause arterial pseudoaneurysms, which may be the cause of massive bleeding, as well as many serious complications. Pseudoaneurysm secondary to chronic pancreatitis is most commonly seen in the splenic artery and then in the gastroduodenal artery. Various factors need to be considered in the management of splenic artery pseudoaneurysms, including hemodynamic stability, coagulation status, and source of bleeding. In many studies conducted in recent years, transcatheter endovascular embolization in the treatment of peripancreatic hemorrhagic pseudoaneurysms has been presented as a safe alternative to surgery due to high morbidity and mortality rates during surgery. Splenic artery pseudoaneurysm rupture should be kept in mind as a possible cause in massive gastrointestinal hemorrhages of unknown etiology, especially in patients with a previous history of pancreatic surgery, pancreatitis or pseudocyst, and the treatment approach should be determined accordingly.

Anahtar Kelimeler

Coil Embolization, Gastrointestinal Bleeding, Pancreatic Pseudocyst, Splenic Artery Pseudoaneurysm

Pankreatik Psödokist Komplikasyonu: Kistogastrostomi Zemininde Splenik Arter Psödoanevrizma Kanaması

Öz

Pankreas psödokistinin nadir bir komplikasyonu olan splenik arter psödoanevrizmasına bağlı gelişen üst gastrointestinal kanama bulgularıyla başvuran olguya yaklaşımımızı sunmayı amaçladık. Geçirilmiş kronik pankreatit cerrahisi ve gastrojejunostomi ameliyatı ve bu ameliyattan 6 ay sonra gelişen pankreatik psödokiste bağlı endoskopik kistogastrostomi öyküsü bulunan 67 yaş erkek hasta üst gastrointestinal kanama bulgularıyla acil servisimize başvurdu. Radyolojik değerlendirmede splenik arter psödoanerizmasının kistogastrostomi hattına rüptüre olarak kanamaya sebep olduğu saptandı. Girişimsel radyoloji kliniği tarafından yapılan invaziv anjiografide splenik arter psödoanevrizmasına ve erode olmuş olan gastroduodenal artere yönelik koil embolizasyon işlemi gerçekleştiridi. İşlem sonrası kontrol gastroskopide aktif kanamanın durduğu görüldü ve takiplerinde ek kan ürünü replasmanına ihtiyaç duyulmadı. Yoğunbakım takiplerinde ventilatör pnömonisi ve katater sepsisi gelişen hasta, işlem sonrası 10. günde ağır sepsis nedeniyle eksitus oldu. Gastrointestinal kanama bulguları ile başvuran geçirilmiş pankreas cerrahisi ve pankreatik psödokist öyküsü olan hastalarda endoskopik girişimlere ek olarak bilgisayarlı tomografi anjiyografisi ile değerlendirme yapılmalıdır. Pankreas psödokisti birçok ciddi komplikasyonların yanı sıra masif kanamaların sebebi olabilecek arteryal psödoanevrizmalara da neden olabilmektedir. Kronik pankreatite sekonder psödoanevrizma en sık splenik arterde sonra da gastroduodenal arterde görülmektedir. Splenik arter psödoanevrizmalarının yönetiminde hemodinamik stabilite, pıhtılaşma durumu ve kanama kaynağı dahil olmak üzere çeşitli faktörlerin dikkate alınması gerekir. Son yıllarda yapılan birçok çalışmada peripankreatik kanamalı psödoanevrizmaların tedavisinde transkateter endovasküler embolizasyon, cerrahi sırasındaki yüksek morbidite ve mortalite oranları nedeniyle, cerrahiye güvenli bir alternatif olarak sunulmaktadır. Etiyolojisi bilinmeyen masif gastrointestinal kanamalarda, özellikle pankreas cerrahisi, pankreatit veya psödokist öyküsü olan hastalarda, olası bir kanama nedeni olarak splenik arter psödoanevrizması rüptürünün olabileceği akılda tutulmalı ve tedavi yaklaşımı buna göre belirlenmelidir.

Anahtar Kelimeler

Gastrointestinal Kanama, Koil Embolizasyon, Pankreatik Psödokist, Splenik Arter Psödoanevrizması

Kaynakça

• 1. Tan JH, Chin W, Shaikh AL, et al. Pancreatic pseudocyst: Dilemma of its recent management. Exp Ther Med. 2021;21(2):159.
• 2. Jin Z, Xiang YW, Liao QS, et al. Massive gastric bleeding - perforation of pancreatic pseudocyst into the stomach: A case report and review of literature. World J Clin Cases. 2021;9(2):389-395.
• 3. Prette PR, Fagundes FB, Marchon LRC, et al. Endovascular treatment of acute gastrointestinal bleeding from a large splenic artery pseudoaneurysm: Case report and literature review. J Vasc Bras. 2018;17(3):234-42.
• 4. De Rosa A, Gomez D, Pollock J, et al. The radiological management of pseudoaneurysms complicating pancreatitis. JOP. 2012;13(6):660-6.
• 5. Hoshimoto S, Aiura K, Shito M, et al. Successful resolution of a hemorrhagic pancreatic pseudocyst ruptured into the stomach complicating obstructive pancreatitis due to pancreatic cancer: a case report. World J Surg Oncol. 2016;14(1):46.
• 6. Ben Moussa M, Feki MN, Baraket O, et al. Pancreatic pseudocysts complicated by hemorrhage and infection. Tunis Med. 2011;89(4):383–5.
• 7. Gagliano E, Barbuscia MA, Tonante A, et al. Pancreatic pseudocyst: case report and short literature review. G Chir. 2012;33:415–419.
• 8. Tessier DJ, Stone WM, Fowl RJ, et al. Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature. J Vasc Surg. 2003;38(5):969–74.
• 9. Tulsyan N, Kashyap VS, Greenberg RK, et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg. 2007;45(2):276–83.
• 10. Sawicki M, Marlicz W, Czapla N, et al. Massive upper gastrointestinal bleeding from a splenic artery pseudoaneurysm caused by a penetrating gastric ulcer: case report and review of literature. Pol J Radiol. 2015;80:384–7.
• 11. Yagmur Y, Akbulut S, Gumus S, et al. Giant splenic artery pseudoaneurysm: a case report and literature review. Int Surg. 2015;100(7-8):1244-8.
• 12. Bhasin DK, Rana SS, Sharma V, et al. Non-surgical management of pancreatic pseudocysts associated with arterial pseudoaneurysm. Pancreatology. 2013;13(3):250–3.
• 13. Kim J, Shin JH, Yoon HK, et al. Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution. Diagn Interv Radiol. 2015;21:140–147.
• 14. Batagini NC, El-Arousy H, Clair DG, et al. Open versus endovascular treatment of visceral artery aneurysms and pseudoaneurysms. Ann Vasc Surg. 2016;35:1–8.
• 15. Laganà D, Carrafiello G, Mangini M, et al. Multimodal approach to endovascular treatment of visceral artery aneurysms and pseudoaneurysms. Eur J Radiol. 2006;59(1):104–11.
• 16. Klauss M, Heye M, Stampfl U, et al. Successful arterial embolization of a giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis with literature review. J Radiol Case Rep. 2012;6(2):9-16.
• 17. Borzelli A, Amodio F, Pane F, et al. Successful endovascular embolization of a giant splenic artery pseudoaneurysm secondary to a huge pancreatic pseudocyst with concomitant spleen invasion. Pol J Radiol. 2021;86:e489-95.
• 18. Miao YD, Ye B. Intragastric rupture of splenic artery aneurysms: Three case reports and literature review. Pak J Med Sci. 2013;29(2):656-9.