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Endoscopic appearance of gastroduodenal artery aneurysm
H Jamal, K Block
Brief Reports
Endoscopic appearance of gastroduodenal artery aneurysm Hyder Z. Jamal, MD, Kevin P. Block, MD, PhD
Uncommon causes of upper GI bleeding include Dieulafoy’s lesion, arteriovenous malformation, and benign and malignant tumors.1 We describe a case of an elderly man with a gastroduodenal artery (GDA) aneurysm presenting as a bleeding duodenal mass. A Medline search of articles published from 1966 to 1999 failed to reveal a study of the endoscopic appearance of GDA aneurysms. Recognition of such a lesion is essential in preventing endoscopically related adverse outcomes. CASE REPORT An 83-year-old man presented with an acute episode of hematemesis. There was no history of abdominal pain, vomiting, or heartburn. He denied use of aspirin, nonsteroidal anti-inflammatory agents, and alcohol and had no history of peptic ulcer disease, pancreatitis, or chronic liver disease. Medical history was significant for corticosteroid and oxygen-dependent chronic obstructive pulmonary disease, hypertension, and localized bladder cancer. At admission his heart rate was 110 beats/min but there was no orthostatic change in blood pressure. There were no stigmata of chronic liver disease, abdominal tenderness, or enlarged organs. Stool was guaiac positive. Initial laboratory data (normal values in parentheses) included a hematocrit level of 33% (35-45%), white blood cell count of 14,000 (3.8-10.5), and BUN 27 mg/dL. The platelet count and coagulation profile were normal. The hematocrit rose to only 37% after transfusion of 1 unit of packed red cells. From the Department of Medicine, Section of Gastroenterology, University of Wisconsin, Madison, Wisconsin. Reprint requests: Kevin P. Block, MD, PhD, Assistant Professor of Medicine, Section of Gastroenterology, UW Hospital and Clinics, 600 Highland Ave. H6/516 CSC, Madison, WI 53792; fax: 608265-5677. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54/100602 862
GASTROINTESTINAL ENDOSCOPY
Upper endoscopy revealed a 4 to 5 cm mass occupying approximately half of the duodenal bulb with a large ulceration and a friable appearance (Fig.1). No active bleeding was seen and the mass did not appear pulsatile. Biopsy specimens were not taken. Abdominal CT revealed a 4 cm mass in the region of the duodenal sweep consistent with a GDA aneurysm (Fig. 2) located lateral to the uncinate process of the pancreas. The mass was round and regular with a central enhancing nidus representing the patent portion of the aneurysm. Surrounding the nidus was a dense and rounded material consistent with a thrombus. The adjacent duodenal wall was thickened and the pancreatic body and tail appeared normal. A Doppler US confirmed the vascular nature of the mass (Fig. 3). At laparotomy, the GDA aneurysm was double-ligated. Oversewing of a penetrating duodenal ulcer, vagotomy, and pyloroplasty were performed. Postoperatively there was no recurrence of bleeding but the patient developed adult respiratory distress syndrome and respiratory failure requiring mechanical ventilation. He did not recover and expired 8 days after surgery. A request for autopsy was declined.
DISCUSSION Most symptomatic benign duodenal tumors present with fluctuating abdominal pain or intussusception.2 Occult bleeding is also common but hematemesis occurs only rarely.3 Malignant tumors may have a similar presentation but overt bleeding occurs more frequently, especially with leiomyosarcoma.4,5 Visceral artery aneurysms are uncommon and usually involve the splenic, hepatic, or celiac arteries.6 The etiology is unknown but they may be secondary to atherosclerosis. Aneurysms of the GDA are often associated with pancreatic pseudocysts. Aneurysm of GDA is rare; however, with wider application of selective celiac and superior mesenteric artery arteriography for various reasons, including investigation for occult GI bleeding, asymptomatic aneurysms of splanchnic vessels are being discovered more frequently.7 US with color Doppler has been shown to accurately diagnose VOLUME 50, NO. 6, 1999
Brief Reports
Figure 1. Endoscopic view of duodenal bulb showing a friable, ulcerated mass occupying approximately half of the lumen. Note ulcerated area in the center of the mass.
H Jamal, K Block
Figure 3. Doppler US of abdomen showing flow through portal vein (arrowhead) and turbulent flow through the aneurysm (arrow). Pancreas is indicated by white arrows.
GDA aneurysms should be considered in the differential of these masses. Appropriate radiologic imaging including CT and US with color Doppler should be obtained to avoid unwarranted, potentially catastrophic endoscopic interventions. REFERENCES
Figure 2. CT of abdomen with intravenous contrast showing GDA aneurysm. Long arrow shows patent portion of aneurysm with contrast enhancement; star shows thrombus in aneurysm; short arrow shows uncinate portion of pancreas.
aneurysms of the splanchnic artery and also GDA aneurysms.8 GDA aneurysms may present with pain,9 jaundice,10 or hemorrhage.6 Bleeding may occur intraperitoneally, into the retroperitoneal space or into the GI tract, requiring emergency surgical intervention. Occult bleeding occurs less frequently. Among unusual presentations is a single case of secondary portal hypertension due to rupture of a GDA aneurysm into portal vein.11 Sams et al.12 have described a patient with recurrent GI blood loss secondary to rupture of a GDA aneurysm into a pancreatic pseudocyst; at endoscopy, bleeding from the major duodenal papilla (hemosuccus pancreaticus) was noted. The discovery of a duodenal mass on emergency upper endoscopy for hematemesis is uncommon. VOLUME 50, NO. 6, 1999
1. Silverstein FE, Gilbert DA, Tedesco FJ, Buenger NK, Persing J. The national ASGE survey on upper gastrointestinal bleeding. I. Study design and baseline data. Gastrointest Endosc 1981;27:73-80. 2. Herbsman H, Wetstein L, Rosen Y, Orces H, Alfonso AE, Iyer SK, et al. Tumors of the small intestine. Curr Probl Surg 1980;17:121-8. 3. Lance P. Tumors and other neoplastic diseases of the small bowel. In: Yamada T, Alpers DH, Owyang C, Powell DW, Silverstein FE, editors. Textbook of gastroenterology. 2nd edition. Philadelphia: JB Lippincott; 1995. p. 1696-714. 4. Darling RC, Welch CE. Tumors of the small intestine. N Engl J Med 1959;260:397-408. 5. Lynch-Nyhan A, Fishman EK, Kadir S. Diagnosis and management of massive gastrointestinal bleeding owing to duodenal metastasis from renal cell carcinoma. J Urol 1987;138:611-3. 6. Deterling R Jr, Stanley J, Thompson N, Fry W. Splanchnic artery aneurysms. Arch Surg 1970;101,689-96. 7. Sethi GK, Oteen NC, Nelson RM. Gastroduodenal arterial aneurysms: report of a case and review of the literature. Surgery 1976;79:233-5. 8. Yeh TS, Jan YY, Jeng LB, Hwang TL, Wang CS, Chen MF. Massive extra-enteric gastrointestinal hemorrhage secondary to splanchinc artery aneurysms. Hepatogastroenterology 1997;44:1152-6. 9. Abrams R, Kulkarni A, Beranbaum E, Santos JS. Aneurysm of the gastro-duodenal artery. Br J Radiol 1969;42:384-5. 10. Bassaly I, Schwartz I, Pinchuck A, Lerner R. Aneurysm of the gastroduodenal artery presenting as common duct obstruction with jaundice. Am J Gastroenterol 1973;59:435-40. 11. Agrifoglio G, Lorenzi G, Gabrielli L, Teodori T, Frasson F. Rupture of GDA aneurysm into the portal vein. Int Surg 1983;68:279-81. 12. Sams J, Nostrant T, Agha F, Williams D. Gastroduodenal artery aneurysm presenting as chronic gastrointestinal blood loss. Am J Gastroenterol 1986;81:29-32. GASTROINTESTINAL ENDOSCOPY
863
Brief Reports
Endoscopic appearance of gastroduodenal artery aneurysm Hyder Z. Jamal, MD, Kevin P. Block, MD, PhD
Uncommon causes of upper GI bleeding include Dieulafoy’s lesion, arteriovenous malformation, and benign and malignant tumors.1 We describe a case of an elderly man with a gastroduodenal artery (GDA) aneurysm presenting as a bleeding duodenal mass. A Medline search of articles published from 1966 to 1999 failed to reveal a study of the endoscopic appearance of GDA aneurysms. Recognition of such a lesion is essential in preventing endoscopically related adverse outcomes. CASE REPORT An 83-year-old man presented with an acute episode of hematemesis. There was no history of abdominal pain, vomiting, or heartburn. He denied use of aspirin, nonsteroidal anti-inflammatory agents, and alcohol and had no history of peptic ulcer disease, pancreatitis, or chronic liver disease. Medical history was significant for corticosteroid and oxygen-dependent chronic obstructive pulmonary disease, hypertension, and localized bladder cancer. At admission his heart rate was 110 beats/min but there was no orthostatic change in blood pressure. There were no stigmata of chronic liver disease, abdominal tenderness, or enlarged organs. Stool was guaiac positive. Initial laboratory data (normal values in parentheses) included a hematocrit level of 33% (35-45%), white blood cell count of 14,000 (3.8-10.5), and BUN 27 mg/dL. The platelet count and coagulation profile were normal. The hematocrit rose to only 37% after transfusion of 1 unit of packed red cells. From the Department of Medicine, Section of Gastroenterology, University of Wisconsin, Madison, Wisconsin. Reprint requests: Kevin P. Block, MD, PhD, Assistant Professor of Medicine, Section of Gastroenterology, UW Hospital and Clinics, 600 Highland Ave. H6/516 CSC, Madison, WI 53792; fax: 608265-5677. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/54/100602 862
GASTROINTESTINAL ENDOSCOPY
Upper endoscopy revealed a 4 to 5 cm mass occupying approximately half of the duodenal bulb with a large ulceration and a friable appearance (Fig.1). No active bleeding was seen and the mass did not appear pulsatile. Biopsy specimens were not taken. Abdominal CT revealed a 4 cm mass in the region of the duodenal sweep consistent with a GDA aneurysm (Fig. 2) located lateral to the uncinate process of the pancreas. The mass was round and regular with a central enhancing nidus representing the patent portion of the aneurysm. Surrounding the nidus was a dense and rounded material consistent with a thrombus. The adjacent duodenal wall was thickened and the pancreatic body and tail appeared normal. A Doppler US confirmed the vascular nature of the mass (Fig. 3). At laparotomy, the GDA aneurysm was double-ligated. Oversewing of a penetrating duodenal ulcer, vagotomy, and pyloroplasty were performed. Postoperatively there was no recurrence of bleeding but the patient developed adult respiratory distress syndrome and respiratory failure requiring mechanical ventilation. He did not recover and expired 8 days after surgery. A request for autopsy was declined.
DISCUSSION Most symptomatic benign duodenal tumors present with fluctuating abdominal pain or intussusception.2 Occult bleeding is also common but hematemesis occurs only rarely.3 Malignant tumors may have a similar presentation but overt bleeding occurs more frequently, especially with leiomyosarcoma.4,5 Visceral artery aneurysms are uncommon and usually involve the splenic, hepatic, or celiac arteries.6 The etiology is unknown but they may be secondary to atherosclerosis. Aneurysms of the GDA are often associated with pancreatic pseudocysts. Aneurysm of GDA is rare; however, with wider application of selective celiac and superior mesenteric artery arteriography for various reasons, including investigation for occult GI bleeding, asymptomatic aneurysms of splanchnic vessels are being discovered more frequently.7 US with color Doppler has been shown to accurately diagnose VOLUME 50, NO. 6, 1999
Brief Reports
Figure 1. Endoscopic view of duodenal bulb showing a friable, ulcerated mass occupying approximately half of the lumen. Note ulcerated area in the center of the mass.
H Jamal, K Block
Figure 3. Doppler US of abdomen showing flow through portal vein (arrowhead) and turbulent flow through the aneurysm (arrow). Pancreas is indicated by white arrows.
GDA aneurysms should be considered in the differential of these masses. Appropriate radiologic imaging including CT and US with color Doppler should be obtained to avoid unwarranted, potentially catastrophic endoscopic interventions. REFERENCES
Figure 2. CT of abdomen with intravenous contrast showing GDA aneurysm. Long arrow shows patent portion of aneurysm with contrast enhancement; star shows thrombus in aneurysm; short arrow shows uncinate portion of pancreas.
aneurysms of the splanchnic artery and also GDA aneurysms.8 GDA aneurysms may present with pain,9 jaundice,10 or hemorrhage.6 Bleeding may occur intraperitoneally, into the retroperitoneal space or into the GI tract, requiring emergency surgical intervention. Occult bleeding occurs less frequently. Among unusual presentations is a single case of secondary portal hypertension due to rupture of a GDA aneurysm into portal vein.11 Sams et al.12 have described a patient with recurrent GI blood loss secondary to rupture of a GDA aneurysm into a pancreatic pseudocyst; at endoscopy, bleeding from the major duodenal papilla (hemosuccus pancreaticus) was noted. The discovery of a duodenal mass on emergency upper endoscopy for hematemesis is uncommon. VOLUME 50, NO. 6, 1999
1. Silverstein FE, Gilbert DA, Tedesco FJ, Buenger NK, Persing J. The national ASGE survey on upper gastrointestinal bleeding. I. Study design and baseline data. Gastrointest Endosc 1981;27:73-80. 2. Herbsman H, Wetstein L, Rosen Y, Orces H, Alfonso AE, Iyer SK, et al. Tumors of the small intestine. Curr Probl Surg 1980;17:121-8. 3. Lance P. Tumors and other neoplastic diseases of the small bowel. In: Yamada T, Alpers DH, Owyang C, Powell DW, Silverstein FE, editors. Textbook of gastroenterology. 2nd edition. Philadelphia: JB Lippincott; 1995. p. 1696-714. 4. Darling RC, Welch CE. Tumors of the small intestine. N Engl J Med 1959;260:397-408. 5. Lynch-Nyhan A, Fishman EK, Kadir S. Diagnosis and management of massive gastrointestinal bleeding owing to duodenal metastasis from renal cell carcinoma. J Urol 1987;138:611-3. 6. Deterling R Jr, Stanley J, Thompson N, Fry W. Splanchnic artery aneurysms. Arch Surg 1970;101,689-96. 7. Sethi GK, Oteen NC, Nelson RM. Gastroduodenal arterial aneurysms: report of a case and review of the literature. Surgery 1976;79:233-5. 8. Yeh TS, Jan YY, Jeng LB, Hwang TL, Wang CS, Chen MF. Massive extra-enteric gastrointestinal hemorrhage secondary to splanchinc artery aneurysms. Hepatogastroenterology 1997;44:1152-6. 9. Abrams R, Kulkarni A, Beranbaum E, Santos JS. Aneurysm of the gastro-duodenal artery. Br J Radiol 1969;42:384-5. 10. Bassaly I, Schwartz I, Pinchuck A, Lerner R. Aneurysm of the gastroduodenal artery presenting as common duct obstruction with jaundice. Am J Gastroenterol 1973;59:435-40. 11. Agrifoglio G, Lorenzi G, Gabrielli L, Teodori T, Frasson F. Rupture of GDA aneurysm into the portal vein. Int Surg 1983;68:279-81. 12. Sams J, Nostrant T, Agha F, Williams D. Gastroduodenal artery aneurysm presenting as chronic gastrointestinal blood loss. Am J Gastroenterol 1986;81:29-32. GASTROINTESTINAL ENDOSCOPY
863