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Ruptured splenic artery aneurysm masquerading as a gastric hemorrhage
Ruptured splenic artery aneurysm masquerading as a gastric hemorrhage Patrick Scheiermann, MD,a Georgios Meimarakis, MD,b Fabian Bamberg, MD, MPH,c and Florian Weis, MD,a Munich, Germany
A 69-year-old woman was brought into the emergency department of our hospital. Initially, she had complained about epigastric and back pain before becoming unconscious due to persistent arterial hypotension. A focused ultrasound examination of the abdomen did not show any free intra-abdominal fluid. The arterial hemoglobin concentration was 5.1 g/dL. Increasing doses of vasopressive agents enabled an emergency computed tomography (CT) scan. The patient’s condition deteriorated dramatically, and CT interpretation had to be performed in an extremely urgent manner. Axial (A) and sagittal (B) images through the abdomen demonstrated a large thrombus-filled (T) lesser sac (arrowheads), and the stomach was collapsed (white arrow). This large, well-defined arterial mass in the left upper abdomen was consistent with a gastric hemorrhage and was considered to be the source of the patient’s hemodynamic instability. An emergency gastrotomy failed to reveal any gastric source of active bleeding. Instead, massive hemorrhage from the omental bursa was caused by a ruptured splenic artery aneurysm (SAA; C). According to a three-dimensional volume-rendered reconstruction of the CT imaging, the huge SAA extended to the splenic hilum. The imaging (D) showed the ruptured aneurysm (arrowheads) of the splenic artery (asterisk), including the renal artery and renal parenchyma (white arrows) as well as the superior mesenteric artery (black arrow). The patient underwent ligation of the splenic artery and subsequent splenectomy and was transferred to the surgical intensive care unit. She fully recovered and was discharged to rehabilitation 6 weeks after admission. DISCUSSION Persistent arterial hypotension after complaints of epigastric or back pain is the key characteristic of a ruptured abdominal aortic aneurysm.1 In contrast, a ruptured SAA is rare.2 The focused ultrasound examination excluded an intraperitoneal hemorrhage as the source of the patient’s poor hemodynamic condition. However, arterial hypotension and anemia were highly suggestive of intra-abdominal bleeding. A CT scan may be considered for operative planning in patients with intra-abdominal hemorrhage who are hemodynamically compensated. In this patient, primarily gastric hemorrhage was suggested to be the cause of her hemodynamic instability because a bleeding gastric ulcer is frequent in emergency department admissions, with patients presenting with arterial hypotension and low blood hemoglobin levels. Ruptured SAA masquerading as a gastric hemorrhage is an uncommon presentation of a rare vascular disease. Most patients with SAA present in a compensated clinical condition and can undergo medical imaging for operative planning. In this particular clinical setting, the value of abdominal CT scan remains controversial. We believe that, retrospectively, CT scan could have been omitted for reasons of timely transport of the patient to the operating theater. REFERENCES 1. Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg 2009;50:880-96. 2. Trastek VF, Pairolero PC, Joyce JW, Hollier LH, Bernatz PE. Splenic artery aneurysms. Surgery 1982;91:694-9. Submitted Apr 19, 2011; accepted Oct 5, 2011. From the Departments of Anesthesiology,a Surgery,b and Radiology,c Hospital of the Ludwig-Maximilians-University, Campus Grosshadern. Author conflict of interest: none. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2012;56:509 0741-5214/$36.00 Copyright © 2012 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.10.004
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A 69-year-old woman was brought into the emergency department of our hospital. Initially, she had complained about epigastric and back pain before becoming unconscious due to persistent arterial hypotension. A focused ultrasound examination of the abdomen did not show any free intra-abdominal fluid. The arterial hemoglobin concentration was 5.1 g/dL. Increasing doses of vasopressive agents enabled an emergency computed tomography (CT) scan. The patient’s condition deteriorated dramatically, and CT interpretation had to be performed in an extremely urgent manner. Axial (A) and sagittal (B) images through the abdomen demonstrated a large thrombus-filled (T) lesser sac (arrowheads), and the stomach was collapsed (white arrow). This large, well-defined arterial mass in the left upper abdomen was consistent with a gastric hemorrhage and was considered to be the source of the patient’s hemodynamic instability. An emergency gastrotomy failed to reveal any gastric source of active bleeding. Instead, massive hemorrhage from the omental bursa was caused by a ruptured splenic artery aneurysm (SAA; C). According to a three-dimensional volume-rendered reconstruction of the CT imaging, the huge SAA extended to the splenic hilum. The imaging (D) showed the ruptured aneurysm (arrowheads) of the splenic artery (asterisk), including the renal artery and renal parenchyma (white arrows) as well as the superior mesenteric artery (black arrow). The patient underwent ligation of the splenic artery and subsequent splenectomy and was transferred to the surgical intensive care unit. She fully recovered and was discharged to rehabilitation 6 weeks after admission. DISCUSSION Persistent arterial hypotension after complaints of epigastric or back pain is the key characteristic of a ruptured abdominal aortic aneurysm.1 In contrast, a ruptured SAA is rare.2 The focused ultrasound examination excluded an intraperitoneal hemorrhage as the source of the patient’s poor hemodynamic condition. However, arterial hypotension and anemia were highly suggestive of intra-abdominal bleeding. A CT scan may be considered for operative planning in patients with intra-abdominal hemorrhage who are hemodynamically compensated. In this patient, primarily gastric hemorrhage was suggested to be the cause of her hemodynamic instability because a bleeding gastric ulcer is frequent in emergency department admissions, with patients presenting with arterial hypotension and low blood hemoglobin levels. Ruptured SAA masquerading as a gastric hemorrhage is an uncommon presentation of a rare vascular disease. Most patients with SAA present in a compensated clinical condition and can undergo medical imaging for operative planning. In this particular clinical setting, the value of abdominal CT scan remains controversial. We believe that, retrospectively, CT scan could have been omitted for reasons of timely transport of the patient to the operating theater. REFERENCES 1. Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg 2009;50:880-96. 2. Trastek VF, Pairolero PC, Joyce JW, Hollier LH, Bernatz PE. Splenic artery aneurysms. Surgery 1982;91:694-9. Submitted Apr 19, 2011; accepted Oct 5, 2011. From the Departments of Anesthesiology,a Surgery,b and Radiology,c Hospital of the Ludwig-Maximilians-University, Campus Grosshadern. Author conflict of interest: none. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2012;56:509 0741-5214/$36.00 Copyright © 2012 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.10.004
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