Hemosuccus Pancreaticus Associated with Segmental Arterial Mediolysis Successfully Treated by Transarterial Embolization
Abstract
Context Hemosuccus pancreaticus, a rare cause of intermittent upper gastrointestinal bleeding, is usually caused by the rupture of an aneurysm associated with chronic pancreatitis. Segmental arterial mediolysis is a rare non-arteriosclerotic, non-inflammatory vascular disease characterized by vacuolization and lysis of the arterial smooth muscle cells. Segmental arterial mediolysis often causes intra-abdominal hemorrhage through aneurysm rupture. To our knowledge, hemosuccus pancreaticus associated with segmental arterial mediolysis has not previously been reported. Case report A 59-year-old man had suffered from recurrent episodes of epigastric pain and melena. Laboratory data showed mild anemia and an elevated serum amylase level. Upper gastrointestinal endoscopy revealed bloody pancreatic juice exuding from the papilla of Vater. There were no findings suggestive of chronic pancreatitis, such as pancreatic calcification, irregularity of the pancreatic duct and atrophy of the pancreas. Contrast-enhanced computed tomography revealed a large fusiform aneurysm of the middle-distal splenic artery, and dissection of the proximal splenic artery and celiac artery. Leakage of contrast medium from the aneurysm into the main pancreatic duct was also evident. Angiography clearly revealed a fusiform aneurysm of the splenic artery. This was managed successfully by transarterial coil embolization and the patient has subsequently shown no recurrence of epigastric pain or melena. Conclusion Segmental arterial mediolysis is a very rare cause of hemosuccus pancreaticus not associated with chronic pancreatitis. Transcatheter arterial embolization is useful for treatment of ruptured aneurysm associated with segmental arterial mediolysis.
Image: 3D-CT angiography showing a leakage of contrast medium from a fusiform aneurysm of the middle-distal splenic artery.
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References
Sandblom P. Gastrointestinal hemorrhage through the pancreatic duct. Ann Surg 1970; 171:61-6. [PMID 5308032]
Wagner WH, Cossman DV, Treiman RL, Foran RF, Levin PM, Cohen JL. Hemosuccus pancreaticus from intraductal rupture of a primary splenic artery aneurysm. J Vasc Surg 1994; 19:158-64. [PMID 8301728]
Toyoki Y, Hakamada K, Narumi S, Nara M, Ishido K, Sasaki M. Hemosuccus pancreaticus: problems and pitfalls in diagnosis and treatment. World J Gastroenterol 2008; 14:2776-9. [PMID 18461665]
Lermite E, Regenet N, Tuech JJ, Pessaux P, Meurette G, Bridoux V, et al. Diagnosis and treatment of hemosuccus pancreaticus: development and endovascular management. Pancreas 2007; 34:229-32- [PMID 17312462]
Slavin RE, Saeki K, Bhagavan B, Maas AE. Segmental arterial mediolysis; a precursor to fibromuscular dysplasia? Mod Pathol 1995; 8:287-94. [PMID 7617656]
Sakano T, Morita K, Imaki M, Ueno H. Segmental arterial mediolysis studied by repeated angiography. Br J Radiol 1997; 70:656-8. [PMID 9227264]
Slavin RE, Gonzales-Vitale JC. Segmental mediolytic arteritis: a clinical pathological study. Lab Invest 1976; 35:23-9. [PMID 940319]
Slavin RE, Cafferty L, Cartwright J Jr. Segmental mediolytic arteritis: A clinicopathologic and ultrastructural study of two cases. Am J Surg Pathol 1989; 13:558-68. [PMID 2660608]
Michael M, Widmer U, Wildermuth S, Barghorn A, Duewell S, Pfammatter T. Segmental arterial mediolysis: CTA findings at presentation and follow-up. AJR Am J Roentgenol 2006; 187:1463-9. [PMID 17114538]
Shimohira M, Ogino H, Sasaki S, Ishikawa K, Koyama M, Watanabe K, Shibamoto Y. Transcatheter arterial embolization for segmental arterial mediolysis. J Endovasc Ther 2008; 15:493-7. [PMID 18729557]
Massani M, Bridda A, Caratozzolo, Bonariol L, Antoniutti M, Bassi N. Hemosuccus pancreaticus due to primary splenic artery aneurysm: a diagnostic and therapeutic challenge. JOP. J Pancreas (Online) 2009; 10:48-52. [PMID 19129615]
Peroux JL, Arput JP, Saint-Paul MC, Dumas R, Hastier P, Caroli FX, et al. Wirsungorrhagia complicating chronic pancreatitis associated with a neuroendocrine tumor of the pancreas. Gastroenterol Clin Biol 1994; 18:1142-5. [PMID 7750689]
Cahow CE, Gusberg RJ, Gottlieb LJ. Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic psedocysts. Am J Surg 1983; 145:534-41. [PMID 6601464]
Begelman SM, Olin JW. Fibromuscular dysplasia. Curr Opin Rheumatol 2000; 12:41-7. [PMID 10647953]
Heritz DM, Butany J, Johnston KW, Sniderman KW. Intraabdominal hemorrhage as a result of segmental mediolytic arteritis of an omental artery: case report. J Vasc Surg 1990; 12:561-5. [PMID 2231968]
EI Hamel A, Parc R, Adda G, Bouteloup PY, Huguet C, Malafosse M. Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis. Br J Surg 1991; 78:1059-63. [PMID 1933185]
Copyright (c) 2010 Itaru Naitoh, Tomoaki Ando, Masashi Shimohira, Takahiro Nakazawa, Kazuki Hayashi, Fumihiro Okumura, Katsuyuki Miyabe, Michihiro Yoshida, Hiroyuki Togawa, Shigeru Sasaki, Yuta Shibamoto, Takashi Joh
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