CLINICAL HISTORY: 
A 35-year-old male patient presented with history of massive hemoptysis associated with pain abdomen and breathlessness since the past 3 days. Patient had no prior co-morbidities; however was a chronic alcoholic and smoker since the past 15 years. No hospital admissions in the past

Kini, Divya Vishwanatha, Dr

Raj, Vinay, Dr

English

Research Connect

JSS Academy of Higher Education and Research Research Connect Radiology Teaching Files 2021 Splenic artery pseudoaneurysm secondary to necrotizing pancreatitis – A rare lethal complication Vinay Raj Dr JSS Medical College, JSSAHER Divya Vishwanatha Kini Dr JSS Medical College, JSSAHER Follow this and additional works at: https://rescon.jssuni.edu.in/radiologyteachingfiles  Part of the Dentistry Commons, Health Policy Commons, Medical Education Commons, Pharmacy and Pharmaceutical Sciences Commons, and the Public Health Education and Promotion Commons Recommended Citation Raj, Vinay Dr and Kini, Divya Vishwanatha Dr, "Splenic artery pseudoaneurysm secondary to necrotizing pancreatitis – A rare lethal complication" (2021). Radiology Teaching Files. 6. https://rescon.jssuni.edu.in/radiologyteachingfiles/6 This Abdominal Imaging is brought to you for free and open access by Research Connect. It has been accepted for inclusion in Radiology Teaching Files by an authorized administrator of Research Connect. Splenic artery pseudo-aneurysm secondary to necrotizing pancreatitis –  A rare lethal complication.  A. CLINICAL HISTORY: A 35-year-old male patient presented with history of massive hemoptysis associated with pain abdomen and breathlessness since the past 3 days. Patient had no prior co-morbidities; however was a chronic alcoholic and smoker since the past 15 years. No hospital admissions in the past.  B. OTHER INVESTIGATIONS:  ▪ Lab investigations – Hemoglobin – 6.9mg/dL (Reduced), Counts – 229560 cells/mm3, Amylase – 64U/L, Lipase – 97U/L (Elevated), and Rest of the investigations were within normal limits. ▪ Upper GI Endoscopy – Smooth extrinsic compression noted over the greater curvature with adherent blood clot. Altered blood noted in the region of the body, antrum and pylorus.  C. IMAGING: CT ABDOMEN & PEVIS (AXIAL PLAIN) – Fig 1 ▪ Well-defined rounded hypodense lesion measuring ~ 7 x 6.2cm in the region of the tail of pancreas with a peripheral layered rim of hyperdensity .                 1Raj and Kini: Splenic artery pseudoaneurysm secondary to necrotizing pancreatitPublished by Research Connect, 2021 CT ABDOMEN & PELVIS (AXIAL & CORONAL - ARTERIAL PHASE) – Fig 2 and 3 ▪ Saccular narrow necked out-pouching from the mid splenic artery with intense enhancement. No e/o active contrast extravasation / calcification – S/o Large saccular pseudo-aneurysm.                 2Radiology Teaching Files, Art. 6 [2021]https://rescon.jssuni.edu.in/radiologyteachingfiles/6 CT ABDOMEN & PELVIS (AXIAL – VENOUS PHASE) – Fig 4 - 7 ▪ Pseudoaneurysm. No e/o active contrast extravasation. ▪ Significantly thickened adjacent posterior wall of the stomach (11mm) with hyper-enhancing mucosa and poorly maintained fat planes.  ▪ Multiple Splenic Infarcts. ▪ Bulky pancreatic body with few non-enhancing areas and peri-pancreatic fat stranding. ▪ Peripherally enhancing collection replacing the tail of the pancreas with pseudoaneurysm within and relatively hyperdense contents (plain CT value of ~ 30HU). ▪ Splenic vein thrombosis.       D. DIAGNOSIS:    ▪ Acute on chronic necrotising pancreatitis with walled off necrosis and large well-defined saccular splenic artery pseudoaneurysm within. (Modified CTSI score 8/10). ▪ Splenic vein thrombosis with collateral formation. ▪ Splenic infarcts.    3Raj and Kini: Splenic artery pseudoaneurysm secondary to necrotizing pancreatitPublished by Research Connect, 2021 E. FOLLOW UP – Fig 8-10  ▪ Coil embolization was performed by utilising the “Sandwich” technique wherein splenic artery proximal and distal to the pseudo-aneurysm was embolized. ▪ Figure 8 – DSA selective angiogram of the splenic artery showing the contrast filled pseudoaneurysm arising from the mid segment of the splenic artery. ▪ Fig 9 – Distal coil embolization done. Absent flow of contrast in the distal splenic artery and to the splenic parenchyma noted. ▪ Fig 10 – Proximal embolization done. Absent contrast opacification of the pseudoaneurysm noted.              F. DISCUSSION:  Epidemiology  ▪ Vascular complications secondary to pancreatitis seldom occur, venous system being affected more than the arterial system (1.3-10%). Arterial pseudo-aneurysms are known to contribute to about 60% of necrotizing pancreatitis cases presenting with acute hemorrhage. (1)   4Radiology Teaching Files, Art. 6 [2021]https://rescon.jssuni.edu.in/radiologyteachingfiles/6Pathogenesis  ▪ Splenic artery pseudo-aneurysms are most commonly seen in the setting of splenic trauma, pancreatitis or mycotic infections. (2, 3) ▪ Pancreatitis is knows to present with non-vascular complications such as collections and aslo vascular complications such as pseudoaneurysms or venous thrombosis.  ▪ In Pancreatitis, there is extensive ongoing inflammation with increased activity of proteolytic and lipolytic enzymes.  ▪ Acinar damage results in release of these enzymes which cause disruption of adjacent arterial walls resulting in catastrophic haemorrhage or hematoma formation or pseudoaneurysm formation. (1) ▪ Most commonly affected vessel in a setting of pancreatitis is splenic artery followed by the gastro-duodenal artery and pancreatico-duodenal vessels. (1) Imaging  ▪ Pseudoaneurysms occur due to destruction of the arterial wall. Points favouring the diagnosis are – Irregular outline, eccentric thrombus, adjacent features pointing to the likely etiology (Inflammation, trauma). (4) ▪ The pseudo-aneurysm is seen as brightly enhancing saccular out-pouching in the arterial phase images (similar to the arterial system). Thrombosis within the aneurysm is noted as peripheral non-enhancing areas. ▪ Digital subtraction angiography is the gold standard as a diagnostic as well as a therapeutic option to perform embolisation. ▪ Coil embolization by “Sandwich” technique is the method of choice owing to increased ability of collateralised flow to develop around the splenic artery. (3) Other option include “Sac-packing” technique wherein the aneurysm cavity is filled with embolizing coils / liquid embolizing agents. Conclusion ▪ Accurate and early diagnosis of the vascular complications by CT angiography has crucial role in delineating the anatomy to plan further intervention.  REFERENCES: 1. Evans RP, Mourad MM, Pall G, Fisher SG, Bramhall SR. Pancreatitis: Preventing catastrophic haemorrhage. World Journal of gastroenterology. 2017 Aug 14;23(30):5460. 2. Jesinger RA, Thoreson AA, Lamba R. Abdominal and pelvic aneurysms and pseudoaneurysms: imaging review with clinical, radiologic, and treatment correlation. Radiographics. 2013 May;33(3):E71-96. 3. Agrawal GA, Johnson PT, Fishman EK. Splenic artery aneurysms and pseudoaneurysms: clinical distinctions and CT appearances. American Journal of Roentgenology. 2007 Apr;188(4):992-9. 4. Madhusudhan KS, Venkatesh HA, Gamanagatti S, Garg P, Srivastava DN. Interventional radiology in the management of visceral artery pseudoaneurysms: a review of techniques and embolic materials. Korean journal of radiology. 2016 Jun 1;17(3):351-63. 5Raj and Kini: Splenic artery pseudoaneurysm secondary to necrotizing pancreatitPublished by Research Connect, 2021

Splenic artery pseudoaneurysm secondary to necrotizing pancreatitis – A rare lethal complication

oai:rescon.jssuni.edu.in:radiologyteachingfiles-1004CLINICAL HISTORY: 
A 35-year-old male patient presented with history of massive hemoptysis associated with pain abdomen and breathlessness since the past 3 days. Patient had no prior co-morbidities; however was a chronic alcoholic and smoker since the past 15 years. No hospital admissions in the pas

Splenic artery pseudo-aneurysm secondary to necrotizing pancreatitis – A rare lethal complication.

https://rescon.jssuni.edu.in/cgi/viewcontent.cgi?article=1006&context=radiologyteachingfiles

Splenic artery pseudoaneurysm secondary to necrotizing pancreatitis – A rare lethal complication

Abstract

Similar works

Full text

Available Versions

Research Connect

Research Connect