Massive upper gastrointestinal haemorrhage due to direct visceral erosion of splenic artery aneurysm.RB Shahani, RS Bijlani, AN Dalvi, HK Shah, AB Samsi
Dept. of Surgery, KEM Hospital, Parel, Bombay, Maharashtra.
Six male patients (age group: 30-60 years) with aneurysm of the splenic artery presented with massive upper gastrointestinal tract hemorrhage. Five patients presented with hematemesis and one with melena. Chronic pancreatitis was noted in all the patients, four of whom were chronic alcoholics. Endoscopy was not useful in diagnosis. Bleeding through the Ampulla of Vater was seen in the patient with melena. Angiography was diagnostic in all. Pancreatic resection including the aneurysm(2), and bipolar ligation with underrunning of the aneurysm (3) were the operative procedures. Distal pancreatectomy with pancreatogastrostomy was carried out in the patient with hemosuccus pancreaticus. If endoscopy is inconclusive, angiography and early intervention is recommended to reduce the high mortality associated with conservative management.
Keywords: Adult, Aneurysm, complications,Case Report, Gastrointestinal Hemorrhage, etiology,Human, Male, Middle Age, Rupture, Spontaneous, Splenic Artery,
Massive upper gastrointestinal haemorrhage can be a catastrophic event in practice unless diagnosed early. Emergency endoscopy though useful in determining the exact source and cause, may not do so in all instances. Gastrointestinal haemorrhage associated with pancreatitis occurs primarily into a pseudocyst, and then into a viscus. Six cases of direct rupture of a splenic artery aneurysm into a viscus, a rare occurrence especially in pancreatitis, are reported here.
Case 1: A 40-year-old male, chronic alcoholic, presented with intermittent bouts of hematemesis. After resuscitation from hypovolemic shock, emergency upper gastrointestinal endoscopy revealed fresh blood in the stomach without varices or ulceration. Angiography revealed an aneurysm of the splenic artery, 2 cm in diameter, with spillage of dye into the stomach confirming the diagnosis of splenic artery aneurysm bleeding into the stomach [Figure - 1].
At operation, the aneurysm was seen near the tail of a fibrosed pancreas and had eroded directly into the posterior aspect of the body of the stomach. Bipolar ligation of the aneurysm was done in view of the patient's unstable condition. The anterior wall of the stomach was sutured in 2 layers. This patient had an uneventful recovery.
Case 2: BKI, a 42-year-old male was referred for recurrent bleeding after having undergone a blind partial gastrectomy for haematemesis. Barium studies prior to the surgery were apparently normal. Besides an anaemic state (Hb 8 gm%), the clinical examination was unremarkable. Endoscopy couldn't pinpoint a possible source of bleed. Angiography revealed a large saccular aneurysm arising from the terminal portion of the splenic artery. The pancreas was studded with areas of calcification. Splenectomy with excision of the aneurysm and the involved tail of the pancreas was performed. Recovery was uneventful
Case 3: LM, a 45-year-old non-alcoholic male was operated in a district hospital for massive haematemesis. At exploration, bleeding was identified to be coming from the posterior aspect of the stomach. Attempt at local control of bleeding failed. Opening of the lesser sac revealed the bleeding site to be from one major vessel. The lesser sac was packed and the patient transferred to our institution. At re-exploration, a bleeding aneurysm of the splenic artery was detected. Bipolar ligation and excision of the aneurysm was carried out. Post-operative bronchopneumonia was successfully managed with antibiotics.
Case 4: VP, a 55-year-old chronic alcoholic was admitted with a history of 2 bouts of haematemesis and malaena, but no active bleeding ascites with moderate splenomegaly suggested portal hypertension. Upper gastrointestinal endoscopy however, showed no varices. Sonography revealed numerous collaterals near the hilum of the spleen without varices. During a bout of massive haematemesis, endoscopy was negative for varices, ulcer or erosions. Vasopressin could not control the bleeding. Angiography revealed a splenic artery aneurysm with multiple collateral venous channels. At exploration, splenectomy with excision of the aneurysm combined with extensive neevascularisation of the stomach and the lower oesophagus (in view of portal hypertension) was carried out. The patient developed hepatic encephalopathy, ascitic leak, renal failure, septicaemia and died on the 11th post-operative day.
Case 5: SS, a 55-year-old male, a known alcoholic was admitted with persistent malaena, severe anaemia (Hb: 6.5 gm%) but no haematemesis. Endoscopic examination revealed blood oozing from the ampulla of Vater. Sonography revealed changes of chronic pancreatitis with a dilated duct and an aneurysmal dilatation of the splenic artery in the region of the tail of the pancreas. Angiography revealed a saccular dilatation of the splenic artery. At surgery, splenectomy with excision of the aneurysm and involved tail of pancreas was carried out. Anastomosis between the cut end of the pancreatic duct and the posterior wall of the stomach was done in two layers. The patient had an uneventful recovery.
Case 6: VM, a 34-year-old male, chronic alcoholic, was admitted with a history of three bouts of haematemesis. History and examination (besides anaemia) was non-contributory. Upper gastrointestinal endoscopy showed hypertrophic folds of mucosa on the posterior wall of the stomach. Sonography revealed evidence of chronic pancreatitis with aneurysmal dilatation of the splenic artery. Angiography confirmed the finding of splenic artery aneurysm. At surgery, the aneurysm was seen to have eroded into the posterior wall of the stomach with a thin membrane separating the two. Attempts at separating it from the stomach led to bleeding from the aneurysm necessitating bipolar ligation with under-running of the aneurysm. The opening in the stomach was closed. The patient had an uneventful post-operative recovery.
Splanchnic artery aneurysms are rare. Though splenic artery aneurysm is the commonest of these, its incidence is reported between 0.98% of 1,95,000 autopsies to 10.4% in selective autopsies of elderly patients. Atherosclerosis, arterial dysplasia, pregnancy, other hormonal and hemodynamic events particularly in females, focal arterial inflammatory process like pancreatitis, mycotic embolisms, portal hypertension with splenomegaly and trauma are the common etiological factors described in the formation of these aneurysms. In our series, involving all male patients pancreatitis was the common etiopathologic factor. These aneurysms are asymptomatic with incidental detection. Aneurysmal rupture representing the most serious complication, is low except during the third trimester of pregnancy.
Rupture usually occurs into the lesser sac (including a pseudocyst) initially. In 20% of cases, a small premonitory episode of bleeding occurs followed by free rupture within a short time ("double rupture"),. Haemorrhage directly into a viscus is commonly due to erosion of the gastroduodenal artery into the duodenum .2 Direct rupture of a splenic artery aneurysm into a viscus also occurs as is described in our cases. Ruptures into a splenic vein with creation of an arteriovenous fistula and bleeding into the pancreatic duct have also been reported.
The diagnosis of ruptured splenic artery aneurysms into the gastrointestinal tract can sometimes be missed, especially in alchoholics and in patients with pancreatitis because several more common causes of bleeding could exist in that population. Sonography CT scan, visceral angiography, 99m-Tc blood flow scanning and endoscopic retrograde pancreatography as complementary procedures to endoscopy, have been described in the early and precise diagnosis of this condition. The importance of angiography cannot be overemphasised, as in our cases. In selected cases, control of haemorrhage can be achieved by embolisation,.
The type of operation may vary according to the findings at surgery. Since most aneurysms occur in the distal portion, often in close association with the hilum of the spleen, splenectomy with sufficiently extensive removal of the splenic vessels to include the site of the aneurysm is recommended. However, in the setting of pancreatitis, en bloc removal of the involved pancreas including the aneurysm is recommended as the treatment of choice,. Simple bipolar ligation especially for more proximally situated aneurysms without splenectomy and pancreatic resection has been performed with success. Transcatheter embolisation has recently gained popularity and is now being recommended as the treatment of choice in splanchnic artery aneurysms and pseudoaneurysms. Often an operation can be avoided entirely, or else, temporary control obtained may give valuable time for resuscitation of a patient prior to surgery. Asymptomatic aneurysms should be treated if detected in pregnant women or women of childbearing age. In others, symptomatic aneurysms or those greater than 2.5 cm need treatment.
In summary, the rare condition of rupture of splenic artery aneurysms into the gastrointestinal tract should be considered when endoscopy fails to pinpoint the cause of haemorrhage especially in patients with pancreatitis. Angiography should be done to diagnose this condition. Early intervention is recommended to avert mortality.
[Figure - 1]