Journal of the New Zealand Medical Association, 29-June-2012, Vol 125 No 1357
Gastroduodenal artery (GDA) aneurysms are one of the least common visceral artery aneurysms. Mortality is in the region of 30%.1 The aetiology is poorly understood. Many are the result of pancreatitis but true aneurysms are thought to be caused by arteriosclerosis, peptic ulcer disease, polyarteritis nodosa or Takayasu arteritis.1–3
This report describes a case of haemorrhagic shock due to GDA aneurysm rupture. The patient had a notable history of autoimmune disease.
This 67-year-old woman collapsed at home, with a 3-hour history of sudden onset, severe, epigastric pain radiating to her back. On arrival at the Emergency Department (ED) resuscitation room, she was tachycardic (110 bpm) and hypotensive (60/40 mmHg), requiring aggressive resuscitation. There was no history or sign of melaena, haematochezia or haematemesis.
Whilst in the ED, a bedside ultrasound scan showed free fluid in the subhepatic recess and pelvis, with a normal calibre abdominal aorta. Arterial blood gas demonstrated metabolic acidosis with an elevated lactate level of 5.4 mmol/L.
The patient had recently been diagnosed with multiple sclerosis, for which she had been commenced on low dose prednisone. She also has a history of ankylosing spondylitis and ulcerative colitis. There was no history of aspirin or non-steroidal anti-inflammatory use.
From the ED, the patient was transferred directly to the operating room. An urgent laparotomy was performed. The findings included a significant haemoperitoneum and a large retro-duodenal haematoma. Kocherisation of the duodenum allowed direct visualisation of an actively bleeding gastroduodenal artery. The bleeding vessel was oversewn and clipped. The patient was left with a temporary laparostomy.
Due to the acute nature of this case, there was no opportunity to take any intraoperative photos for the reader, nor was the GDA aneurysm large enough for resection and submission of histology. This surgery was performed by two consultant emergency surgeons and the diagnosis was made intraoperatively by direct visual identification.
Overnight in the Critical Care unit, the patient’s circulation normalised. The next day, she returned to the operating room for a re-look laparotomy, removal of packs and abdominal closure.
CT angiogram prior to discharge showed no evidence of other visceral aneurysms.
Visceral aneurysms have been reported to have an incidence between 0.01% and 10% based on autopsy studies.2,3 Splenic, hepatic and superior mesenteric aneurysms collectively comprise over 85%, whereas aneurysms of the gastroduodenal artery are generally considered one of the least common, representing just 1.5% of the total.2
Despite the infrequency of the occurrence of GDA aneurym, rupture occurs in more than half and brings with it a 20–30% mortality risk.1,2,4. Often patients present in shock and thus the differential diagnosis of visceral artery aneurysm needs to be considered when assessing the shocked patient with abdominal pain.1
The aetiology of visceral aneurysms is poorly understood. GDA aneurysms specifically have been attributed to pancreatitis and pancreatic surgery.1,2, However, it has been estimated that as many as 8% of visceral aneurysms may be attributed to underlying disease, namely Ehlos-Danlos syndrome, fibromuscular dysplasia and polyarteritis nodosum.5
Other conditions to which visceral aneursms may be linked include polymyalgia rheumatica, systemic lupus erythematosus, Takayasu arteritis, neurofibromatosis and Marfans syndrome.2,3 Ankylosing spondylitis has been linked to aortic and coronary aneurysms,6 but no reports seem to previously link this to visceral aneurysms.
The proximity of the gastroduodenal artery to the first part of the duodenum, means it is more common for patients to present with upper gastro-intestinal bleeding due to erosion of this vessel by a duoduenal ulcer. However, as our patient showed no symptoms or signs of this, we suspect that autoimmune disease may be accountable for the ruptured gastroduodenal aneurysm seen at the time of laparotomy.
In summary, we present a recent case of gastroduodenal artery aneurysm rupture to promote discussion and highlight the importance of high clinical suspicion when faced with hypovolaemic shock and an acute-abdomen. We also believe this to be the first report to link GDA rupture to ankylosing spondylitis, supporting previous associations to autoimmune disease.
Author information: Jessica Savage, Surgical Registrar, Auckland City Hospital, Auckland; Li Hsee, Consultant Trauma & Acute Surgeon, Acute Surgical Unit, Department of Surgery, Auckland City Hospital, Auckland
Correspondence: Dr Jessica Savage, Acute Surgical Unit, Department of Surgery, Auckland City Hospital, Private Bag 92 024, Auckland, New Zealand. Email: email@example.com
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