A splenic artery aneurysm presenting with multiple episodes of upper gastrointestinal bleeding: a case report
Splenic artery aneurysm is rare and its diagnosis is challenging due to the nonspecific nature of the clinical presentation. We report a case of a splenic artery aneurysm in which the patient presented with chronic dyspepsia and multiple episodes of minor intragastric bleeding.
A 60-year-old, previously healthy Sri Lankan man presented with four episodes of hematemesis and severe dyspeptic symptoms over a period of 6 months. The results of two initial upper gastrointestinal endoscopies and an abdominal ultrasound scan were unremarkable. A third upper gastrointestinal endoscopy detected a pulsatile bulge at the posterior wall of the gastric antrum. A contrast-enhanced computed tomogram of his abdomen detected a splenic artery aneurysm measuring 3 × 3 × 2.5 cm. While awaiting routine surgery, he developed a torrential upper gastrointestinal bleeding and shock, leading to emergency laparotomy. Splenectomy and en bloc resection of the aneurysm with the posterior stomach wall were performed. Histology revealed evidence for a true aneurysm without overt, acute, or chronic inflammation of the surrounding gastric mucosa. He became completely asymptomatic 2 weeks after the surgery.
Splenic artery aneurysms can result in recurrent upper gastrointestinal bleeding. The possibility of impending catastrophic bleeding should be remembered when managing patients with splenic artery aneurysms after a minor bleeding. Negative endoscopy and ultrasonography should require contrast-enhanced computed tomography to look for the cause of recurrent upper gastrointestinal bleeding.
KeywordsSplenic artery aneurysm True aneurysm Double rupture Intragastric bleeding Case report
Splenic artery aneurysm
Splenic artery aneurysm (SAA) is rare, although it is considered to be the third-most common site for intra-abdominal aneurysms and the most common for splanchnic aneurysms . Incidence ranges from 0.09% in autopsy studies to 0.78% on arteriography studies . Pseudoaneurysms of the splenic artery are rarer, but take bigger sizes and more catastrophic courses than true aneurysms. SAAs are mostly found incidentally, in imaging studies done for various non-related symptoms . Ruptured SAAs can present as acute abdomen with intraperitoneal bleeding, essentially making it a retrospective diagnosis, which often has grave outcomes . Of interest, the rupture of a SAA is more common in males, although SAAs are four times more common in females than in males . We report a case of a 60-year-old man presenting chronic dyspeptic symptoms and several episodes of minor upper gastrointestinal bleeding due to an SAA. The diagnosis of the condition was delayed for 6 months due to non-compliance for advanced imaging, the repeatedly normal endoscopic appearance of the patient’s upper gastrointestinal tract, and the remarkably stable clinical course of the patient in-between minor bleeds, until an episode of torrential intragastric bleeding resulting in hemorrhagic shock.
SAAs are mostly detected incidentally in emergency exploratory laparotomies done for hemoperitoneum, apart from the incidentally found SAAs in various imaging studies. Upper abdominal pain is the most commonly reported symptom for ruptured SAAs [5, 6]. The clinical presentation of unruptured SAA is largely nonspecific and variable [7, 8]. Our patient had severe dyspeptic symptoms for 6 months with minimal abnormalities detected in endoscopic evaluation of his upper gastrointestinal tract. The complete resolution of the symptoms after the excision of the aneurysm and the repeatedly normal endoscopic appearance of gastric mucosa suggest that his chronic dyspeptic symptoms were due to the aneurysm itself. It is not uncommon to observe gastric symptoms resulting from large pseudoaneurysms of the splenic artery. Of interest, in this case, it was a small, spontaneous, true SAA that gave rise to the symptoms. Thus, a mechanism other than pure physical compression of the stomach has to be suspected, resulting in dyspeptic symptoms.
Rupture risk is very low (2 to 3%) for true aneurysms, but it is alarmingly high for pseudoaneurysms (37 to 47%) with 90% mortality . A spontaneous rupture of true SAAs is encountered more with aneurysms larger than 2 cm in diameter and with aneurysms in pregnant women [10, 11, 12, 13, 14]. Patients with intraperitoneal rupture of a SAA present with acute abdomen and hypovolemic shock [15, 16]. Bleeding into the stomach is rare with true SAAs. A few cases of possibly true SAAs with intragastric bleeding were reported, but the histologic confirmation of them being true aneurysms was not confirmed [17, 18]. Unlike true SAAs, intragastric bleeding is a common feature of pseudoaneurysms of the splenic artery [19, 20]. A rare case of a splenic artery pseudoaneurysm fistulating into the transverse colon was reported by O’Brien et al. .
“Double rupture” is a recognized phenomenon for intraperitoneal bleeding of true SAA, with an initial, brief, arrested bleeding into the lesser sac followed by massive bleeding into the peritoneal cavity. Recurrent intragastric bleeding with a stable course over a long period was seen in our patient. The initial endoscopic evaluations were unable to detect any significant abnormality, and the diagnosis was only unveiled with computed tomography of his abdomen. The long delay in making the diagnosis was largely due to the late presentation to a primary care hospital and to the non-compliance of the patient in getting transferred to a tertiary care hospital for advanced imaging. Detecting a pulsatile bulge at the posterior stomach wall expedited arranging contrast-enhanced computed tomography, in this case. The fortunate occurrence of having the first torrential upper gastrointestinal bleeding in a hospital setup with vascular surgical capacities helped to save the life of the patient.
A few cases were reported with interesting workup, to diagnose SAA. A similar case of double rupture of a splenic artery pseudoaneurysm, with initial negative endoscopic and ultrasonography evidence, was reported by Sawicki et al. . Another case of a SAA, first suspected after seeing a non-pulsatile gastric lesion during endoscopy, was reported by Tannoury et al. . Boschmann et al. reported a case where the ultrasound scan of the abdomen was useful in suspecting a SAA in a patient with recurrent gastrointestinal bleeding .
No universally accepted guidelines are available for the management of SAA. However, a number of case series and reviews have outlined a few principles for patient management. Most small (<2.0 cm) asymptomatic SAAs can be monitored effectively with serial imaging . The advent of endovascular techniques to embolize aneurysms has gained popularity over the last decade due to the low morbidity. Transcatheter embolization can be performed with gelatin gels, steel coils, detachable balloons, or glue material. Yet, open surgical exploration and aneurysmectomy remain the gold standard in the management of SAA . Open surgery is essentially the only resort in cases with giant SAA, ruptured SAA, and with SAA complicated with other local and regional pathologies.
The diagnosis of SAA should be considered when no other common pathologies are identified for recurrent upper gastrointestinal bleeding. Endoscopy and ultrasonography are not helpful in excluding an SAA. The possibility of double or multiple ruptures should be borne in mind when managing patients with SAA, after falsely showing hemodynamic stability. Although rare, true SAAs also can result in intragastric rupture with catastrophic gastrointestinal bleeding.
The authors wish to acknowledge the support extended by the staff of the Department of Radiology, National Hospital of Sri Lanka, in providing the images for the compilation of imaging figures.
No funding was received for this study.
Availability of data and materials
WSLD followed up with the patient, compiled the patient details, prepared figures, and wrote the manuscript. SDR, WSLD, and DPJ were involved in decision making, surgery, and perioperative management. DSG reported on histology and provided the histology figures. SDR revised and restructured the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Ethics approval and consent to participate
Ethical approval for the publication of this case report was obtained from the Ethics Review Committee of the National Hospital of Sri Lanka.
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- 19.Sawicki M, Marlicz W, Czapla N, Łokaj M, Skoczylas M, Donotek M, Kołaczyk K. Massive Upper Gastrointestinal Bleeding from a Splenic Artery Pseudoaneurysm Caused by a Penetrating Gastric Ulcer: Case Report and Review of Literature. Pol J Radiol. 2015;80:384–7.CrossRefPubMedPubMedCentralGoogle Scholar
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