Unusual cause of gastrointestinal bleeding in a patient with chronic pancreatitis

Juthipong Benjanuwattra MD, Nouran Eshak MD, MSc, Mahmoud Abdelnabi MD, MSc

Corresponding author: Juthipong Benjanuwattra
Contact Information: Juthipong.Benjanuwattra@ttuhsc.edu
DOI: 10.12746/swrccc.v11i46.1123

CASE

A 40-year-old woman with a history of chronic alcoholic pancreatitis, hypertension, and dyslipidemia presented with a 2-day history of left upper quadrant abdominal pain, hematemesis, and hematochezia. On examination, she had pale conjunctiva, a blood pressure of 136/99 mmHg, and a heart rate of 115 beats per minute. Initial laboratory work-up was remarkable for anemia with a hemoglobin level of 9.0 g/dL and a lipase of 1,306 IU/L. Computed tomography (CT) abdomen showed multiple pancreatic pseudocysts in the pancreatic tail with intrasplenic involvement and suspected splenic artery aneurysm. CT angiography of abdomen revealed a saccular splenic artery aneurysm, measuring 2 cm in diameter, with a mass effect on the pancreatic tail with no active extravasation suggesting no active bleeding (Figure 1A). A trial for coil embolization was unsuccessful because of the proximity to the hilum and tortuosity of the pseudoaneurysm neck (Figure 1B). Conservative management was planned with a close follow-up due to its small size and no active bleeding. Months later, her medical course was complicated by a splenic artery aneurysm rupture requiring splenectomy.


Figure 1

Figure 1. (A) CT angiography of the abdomen showing splenic pseudocyst and suspected splenic artery aneurysm. (B) Angiography showing saccular splenic artery aneurysm.


DISCUSSION

Pancreatic pseudocyst is a common complication of chronic pancreatitis but intrasplenic pseudocyst is quite rare and often associated with the pancreatic tail pseudocyst due to its proximity.1 Splenic hypodense lesions in the setting of chronic pancreatitis raise the suspicion of splenic pseudocysts. The proposed mechanism is pancreatic enzyme-rich fluid erosion into the adjacent vasculatures leads to autodigestion and the formation of a pseudoaneurysm.2 A ruptured splenic artery pseudoaneurysm is fatal without treatment.3 Gastrointestinal hemorrhage may result from rupture and bleeding into the pancreatic duct, a condition known as hemosuccus pancreaticus.4 Endovascular interventions are associated with acceptable outcomes and should be implemented as first-line management.3 Splenectomy and/or distal pancreatectomy may be required for large pseudoaneurysms such as those with rupture into pseudocyst.4 Spontaneously thrombosed pseudoaneurysms were previously reported; however, close follow-up and repeat imaging are mandatory.4

Consent: Informed written consent was obtained from the patient.

Keywords: pancreatitis, pseudocyst, bleeding, aneurysm


REFERENCES

  1. Navarro F, Leiva L, Norero E. Acute abdomen due to pancreatic pseudocyst with splenic extension and rupture. Journal of Surgical Case Reports. 2021 Apr;2021(4):rjab071.
  2. Parikh M, Shah A, Abdellatif A. Splenic artery pseudoaneurysm complicating pancreatitis. J Gen Int Med. 2011 Mar;26(3):343–4.
  3. Dinh Luan N, Duc NM, Hong Son N, et al. A rare case report of acute upper gastrointestinal hemorrhage due to splenic artery pseudoaneurysm. SAGE Open Medical Case Reports. 2021 Dec;9:2050313X211061910.
  4. Tessier DJ, Stone WM, Fowl RJ, et al. Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature. J Vasc Surg. 2003 Nov 1;38(5):969–74.


Article citation: Benjanuwattra J, Eshak N, Abdelnabi M. Unusual cause of gastrointestinal bleeding in a patient with chronic pancreatitis. The Southwest Respiratory and Critical Care Chronicles 2023;11(46):68–69
From: Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
Submitted: 1/2/2023
Accepted: 1/3/2022
Conflicts of interest: none
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