Spontaneous rupture of a left gastroepiploic artery aneurysm.A Rohatgi, T Cherian
Worthing Hospital, Lyndhurst Road, Worthing BN11 2DH, UK.
Gastroepiploic aneurysms are extremely rare. They occur mainly in elderly men and in 90% of cases are ruptured at presentation. Visceral aneurysms though rare should be borne in mind in cases of unexplained haemorrhagic shock. We present a case of a 79-year-old man who presented with abdominal pain, hypotension and anaemia but no obvious source of bleeding. He had undergone a prior aorto-bifemoral graft. The patient refused an operation and died the following day.
Keywords: Aged, Aneurysm, Ruptured, diagnosis,Case Report, Gastroepiploic Artery, Human, Male, Shock, Hemorrhagic, etiology,
Ruptured visceral aneurysms are extremely rare and should be considered in the differential diagnosis of unexplained haemorrhagic shock and also if haemoperitoneum is encountered while performing a laparotomy. Though the mortality is high if untreated, the operation is relatively simple and carries a low risk.
A 79-year-old male was admitted to our hospital from the Accident and Emergency department at 1900 hours complaining of abdominal pain, initially in the lower abdomen but later extending to the epigastric region. There was no history of nausea, vomiting or bowel symptoms. There was a past medical history of aneurysmal disease for which he had undergone an aorto bi-femoral and right femoro-popliteal graft 14 years back. Two months prior to admission he had undergone repair of a left femoral false aneurysm related to the aortic graft anastomosis without any complications. His medical history included atrial fibrillation, chronic obstructive airway disease, hypertension, chronic renal failure, coronary artery disease and a history of left ventricular failure. His initial blood picture was unremarkable with a haemoglobin of 12gm%.
Within five hours of admission, he had two episodes of hypotension, which responded to fluid resuscitation. A full blood screen was repeated which revealed that the haemoglobin had dropped to 5.9 gm%. At this time his abdomen was slightly tender though not ‘peritonitic’. There was no evidence of gastrointestinal bleeding and it was felt that he might be bleeding from the aortic graft site. With a diagnosis of haemorrhagic shock, a decision was made to take the patient for an immediate laparotomy. We felt that a CT scan or ultrasound would not influence our management and so was not requested. It was not possible to obtain the opinion of either a vascular surgeon or an interventional radiologist. His co-morbidities made him a high-risk candidate for any intervention.
The situation was discussed with the patient explaining the risks involved. He felt he had lived a good life and did not want any further intervention. A morphine drip was started and he died peacefully the following day. As the cause of death could not be determine, a post-mortem examination was performed. This revealed a 20mm saccular aneurysm of the left gastroepiploic artery with extensive haemorrhage in the lesser sac and greater omentum. The grafts were intact with no evidence of an anastomotic leak.
Aneurysms of the visceral circulation are rare, accounting for 0.1-10.4% in autopsy statistics;, about 3000 were reported in the literature up to 1999., Splenic artery aneurysms account for 60% followed by hepatic, superior mesenteric and coeliac artery aneurysms.,, Gastric and gastroepiploic aneurysms account for about 4%.,,, The aetiology is related to atherosclerotic (30%), traumatic (25%), inflammatory (15%), infective embolic processes or medial dysplasia and arteritis.,,,,
Gastroepiploic artery aneurysms have an incidence of one tenth of those of the gastric artery., Only 12 were reported till 1999. They occur mainly in men aged 50-60 years with hypertension and atherosclerosis, and most frequently have a pathological finding of medial atherosclerotic degeneration.
The majority of splanchnic aneurysms are asymptomatic. They may present with various symptoms such as epigastric, left/right abdominal pain, intestinal angina, acute abdominal pain, gastrointestinal bleeding, haemoptysis or occult bleeding. Clinical examination may reveal icterus, a bruit or an abdominal lump depending on the location., More than 90% of gastroepiploic aneurysms are ruptured on presentation resulting in haemoperitoneum,,, as in this case. They usually present with mild epigastric pain, haemoperitoneum and haemorrhagic shock requiring some form of intervention.
The diagnosis is generally made on laparotomy for haemodynamic instability, in less urgent cases ultrasonography or CT scan with intra venous contrast can be used., In our case we felt an investigation was not justified as it would not have changed our management. Selective visceral angiography is an accurate method of localisation., Endoscopy is useful if the aneurysm is causing haematemesis and eroding into a gastric mucosal vessel.
There is a 15-40% chance of other aneurysms being present. Hence, the patient should undergo a full vascular examination with the appropriate investigations. We feel that CT angiography of the main visceral vessels may be a useful screening tool in patients diagnosed with more then one aneurysm.
The treatment of splanchnic aneurysms consists of surgery, endovascular embolisation or conservative management.,,
The surgical management consists of resection of the aneurysm, ligation of the feeding vessels or some form of arterial reconstruction. There is one report from Japan of a pseudoaneursym resected laparoscopically with a good result.
Radiological intervention with embolisation of the feeding vessel is an option in splanchnic aneurysms though this has not been reported for gastroepiploic aneurysms as yet.
Observation in splanchnic aneurysms could be employed in the elderly, high risk patient with a small size aneurysm, with embolisation if there is a change in size or if symptoms arise.,
The risk of rupture of aneurysms of the splanchnic artery is 2-20%. The corresponding figures for hepatic artery, coeliac artery, and gastric and gastroepiploic artery are 20-44%, 13% and 90% respectively.,, The risk is extremely low for the superior mesenteric artery. The mortality rate for a ruptured gastroepiploic aneurysm reaches 70%. A search of the literature revealed that ligation of vessels with or without resections is the preferred option, as this is relatively simple and carries a low risk ,,,,,