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Answer to the image of the month question (page 1427)
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IMAGE OF THE MONTH
GASTROENTEROLOGY Vol. 123, No. 5
Answer to the Image of the Month Question (page 1427): Splenic Artery Aneurysms (SAA) A 3-dimensional reconstruction of the arterial phase of the CT scan (Figure 1D) and an in situ image taken at laparotomy (Figure 1E) revealed aneurysms of the splenic artery. A splenectomy and a resection of the splenic artery, including all 3 aneurysms were performed. The aneurysms showed an advanced stage of atherosclerosis. The spleen was enlarged, and showed red pulp hyperplasia and a white pulp atrophy. Extramedullarly granulopoesis, erythropoesis, and megakaryopoesis were identified in the spleen, consistent with the known polycythemia vera. Fourteen days after surgery, the patient was discharged free of pain. SAA are the most common aneurysms of the visceral arteries, but are found in ⬍1% of general autopsies. SAA has its peak incidence between 50 and 80 years of age with the highest incidence in multiparous women.1 Atherosclerosis is considered a major risk factor in elderly individuals, whereas congenital SAA predominates in younger patients.2 SAA are frequently associated with systemic and portal hypertension.2 SAA carry a high risk of rupture (8%) and fatal hemorrhage,1 and approximately 2% of untreated individuals die as a result of an aneurysm complication.2 SAA are usually asymptomatic and are often discovered incidentally. Occasionally, SAA may cause nonspecific symptoms such as acute and chronic abdominal pain and/or cardiovascular collapse due to a rupture. US-scan, Doppler, CT, and magnetic resonance imaging provide valuable noninvasive diagnostic tools and may be combined with an arteriography. Treatment of SAA exceeding a diameter of 3 cm includes resection or transcatheter embolization, whereas asymptomatic SAA smaller than 3 cm do not require surgery. Aneurysms located in the distal third of the splenic artery often require splenectomy.3 This example demonstrates a role of the contrast-enhanced multiphase CT scan in the diagnosis of SAA. In particular, the arterial phase of the CT scan provides a crucial technique in diagnosing SAA because the unenhanced and venous CT phases can be misleading.
References 1. Spittel JA, Fairbairn JF, Kincaid OW, ReMine WH. Aneurysms of the splenic artery. JAMA 1961;175:452– 456. 2. Stanley JC, Fry WJ. Pathogenesis and clinical significance of splenic artery aneurysms. Surgery 1974;76:898 –909. 3. Mattar SG, Lumsden AB. The management of splenic artery aneurysms: experience with 23 cases. Am J Surg 1995;169:580 –584. For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).
IMAGE OF THE MONTH
GASTROENTEROLOGY Vol. 123, No. 5
Answer to the Image of the Month Question (page 1427): Splenic Artery Aneurysms (SAA) A 3-dimensional reconstruction of the arterial phase of the CT scan (Figure 1D) and an in situ image taken at laparotomy (Figure 1E) revealed aneurysms of the splenic artery. A splenectomy and a resection of the splenic artery, including all 3 aneurysms were performed. The aneurysms showed an advanced stage of atherosclerosis. The spleen was enlarged, and showed red pulp hyperplasia and a white pulp atrophy. Extramedullarly granulopoesis, erythropoesis, and megakaryopoesis were identified in the spleen, consistent with the known polycythemia vera. Fourteen days after surgery, the patient was discharged free of pain. SAA are the most common aneurysms of the visceral arteries, but are found in ⬍1% of general autopsies. SAA has its peak incidence between 50 and 80 years of age with the highest incidence in multiparous women.1 Atherosclerosis is considered a major risk factor in elderly individuals, whereas congenital SAA predominates in younger patients.2 SAA are frequently associated with systemic and portal hypertension.2 SAA carry a high risk of rupture (8%) and fatal hemorrhage,1 and approximately 2% of untreated individuals die as a result of an aneurysm complication.2 SAA are usually asymptomatic and are often discovered incidentally. Occasionally, SAA may cause nonspecific symptoms such as acute and chronic abdominal pain and/or cardiovascular collapse due to a rupture. US-scan, Doppler, CT, and magnetic resonance imaging provide valuable noninvasive diagnostic tools and may be combined with an arteriography. Treatment of SAA exceeding a diameter of 3 cm includes resection or transcatheter embolization, whereas asymptomatic SAA smaller than 3 cm do not require surgery. Aneurysms located in the distal third of the splenic artery often require splenectomy.3 This example demonstrates a role of the contrast-enhanced multiphase CT scan in the diagnosis of SAA. In particular, the arterial phase of the CT scan provides a crucial technique in diagnosing SAA because the unenhanced and venous CT phases can be misleading.
References 1. Spittel JA, Fairbairn JF, Kincaid OW, ReMine WH. Aneurysms of the splenic artery. JAMA 1961;175:452– 456. 2. Stanley JC, Fry WJ. Pathogenesis and clinical significance of splenic artery aneurysms. Surgery 1974;76:898 –909. 3. Mattar SG, Lumsden AB. The management of splenic artery aneurysms: experience with 23 cases. Am J Surg 1995;169:580 –584. For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).