Congenital aneurysm of the jejunum

CASE REPORTS

Congenital HENRY

From tbe Department Peoria, Illinois.

HUG,

Aneurysm M.D.* AND CHARLES

D. BRANCH,

ASSIVE

CASE

REPORT

This twenty-two year old white woman, gravida I, para o, was admitted to the hospital on the obstetric service with a pregnancy at term. She was delivered of a normal female infant. There was an uneventfu1 postpartum course until forty-eight hours folIowing the delivery at which time she had two bouts of bleeding from the rectum; the first one was tarry and the second one contained bright red bIood. At the time she was examined it was found that no mass was palpable in the abdomen and there was no tenderness. Proctoscopic examination was then performed and outside of old bIood nothing further was observed. in the rectum, Twenty-four hours later she suddenly went into shock and had numerous stools composed almost entirely of bright red blood. The blood pressure, which had been within normaI limits, fell to 4010 mm. Hg and over a period of three hours she received 4,000 ml. of bIood without any significant * Present

address:

Children’s

M.D., Peoria,

Illinois

rise in the blood pressure. Because of the continuous massive hemorrhage without hematcmesis, and the only manifestation being pure blood passed by operation was advised. Exploratory rectum, laparotomy was carried out through a right rectus incision. On opening the abdomen it was found that from a point 40 cm. from the ligament of Treitz the jejunum, terminal ileum, and colon contained blood. There was no blood above this point. The stomach and jejunum were also normal to inspection and showed no evidence of distention. In the jejunum, approximateIy 40 cm. from the ligament of Treitz, a tumor was palpable. This was quite small and was on the mesenteric side. ObviousIy the bIceding was arising from this mass. A segment of jejunum measuring IO cm. in length and containing the tumor was removed and an end to end anastomosis was performed. The patient’s condition was good following surgery. The hemoglobin was 10.2 gm. and hematocrit 32 per cent. FolIowing this the patient had an uneventfu1 recovery and was discharged seven days after surgery. On gross examination the specimen! consisted of a portion of smaII bowcI measuring IO cm. in length. When opened, a small raised dark red nodularity was found in the mid-portion of the excised loop. This nodularity was 5 mm. in diam-

of Surgery, St. Francis Hospital,

hemorrhage from the gastrointestinal tract is a frequent problem confronting the surgeon. The most common source is the stomach and duodenum. There are numerous etiologic causes found in the small intestine; however, the case to be reported is only the second that we can find in a survey of the literature. Rathmell, Horwell and Greeley (I] in their report reviewed the literature and while they found reports of twentythree patients with rupture of an aneurysm of a gastric artery, no aneurysm was found in the jejunum. They described a patient with an of the jejunum producing fatal aneurysni intestina1 hemorrhage.

M

of the Jejunum

eter, arising from the mcsentcry attachment and was largely submucosal. (Fig. I.) hlicroscopic examination reveaIed a healthy pattern of jejunal mucosa except for the presence of a dilated thick-walled arterial structure which had its base within the submucosal soft tissue resting upon the muscuIaris of the bowel wall. Serial sections discIosed that this was an aneurysmaI development from a normal size medium artery arising in the submucosa. The wall of the aneurysm was scarred and attenuated. lntimal thickening was prominent and the elastic tissue stains showed Ioss of elastic fibers. There was a HobpitaI,

859

BuffaIo, American

New York. .Journal

of Surgery,

Volumr IO.?, Decm~her1061

Hug

Frc. I. Photograph nodularity. perforation mid-portion

of

opened

or rupture of of the mucosal

jejunum

and

Branch

showing

this aneurysm in aspect. (Fig. 2.)

the

FIG. 2. Photomicrograph of nodubity aneurysmal development with perforation. tion X IO.

COMMENTS

showing Magnifica-

inflammation, or positive resuIt of a seroIogic test for syphiIis. By the process of exclusion the lesion was considered to be congenital in origin.

The differentia1 diagnosis of bIeeding from the gastrointestina1 tract has been discussed many times. The fact that this patient had had no vomiting of bIood seemed to rule out the possibiIity of bIeeding from the stomach or esophagus. There was no history of uIcer but, of course, one in the duodenum couId not be ruIed out because hematemesis is not always present. The other possibiIities that could occur in the smaI1 bowe1 such as a poIyp, fibroma and numerous other rare conditions were considered. However, with the patient in such critical condition, immediate operation was performed with Iarge amounts of bIood available for transfusion. Microscopic examination of the section proves this to be an artery. There was no evidence of arterioscIerosis, active

SUMMARY

A second case of massive intestinaI hemorrhage due to rupture of a congenitat aneurysm of the jejunum is reported. This type of a case emphasizes the need for abdomina1 expIoration in those cases in which the source of massive bIeeding cannot be determined. REFERENCE I. RATHMELL, T.

K., HORWELL, R. J. and GREELEY, J. P. Congenital aneurysm of the jejunum producing fata intestinal hemorrhage. Arch. Pad., 51: 461,

860

19s’.