Unusual case of upper gastrointestinal haemorrhage secondary to a ruptured gastroduodenal artery pseudoaneurysm: case presentation and literature review

Abstract

Pseudoaneurysm rupture of the gastroduodenal artery (GDA) is life-threatening and can present as an acute upper gastrointestinal haemorrhage. Here, we present a case of upper gastrointestinal haemorrhage arising from a ruptured GDA pseudoaneurysm. A 56-year-old woman presented acutely with haematemesis. She reported ongoing upper epigastric pain for a few weeks. Laboratory evaluation revealed severe microcytic hypochromic anaemia (haemoglobin, 69 g/L; normal, 120-140 g/L) and a mildly raised serum amylase level. Upper gastrointestinal endoscopy revealed dark blood collection between the rugae of the distal stomach. An abdominal CT scan detected a homogeneously enhancing rounded lesion arising from the GDA adjacent to the second part of the duodenum. The median arcuate ligament was causing stenosis of the coeliac axis origin. The diagnosis of haematemesis secondary to a ruptured GDA pseudoaneurysm was confirmed by mesenteric angiography, and aneurysmal embolisation was done. The haemoglobin level stabilised after aneurysmal embolisation.

Keywords: GI bleeding; interventional radiology; medical education; radiology.

Figure 1

Upper gastrointestinal endoscopy. Note the dark blood within the distal gastric rugae (red arrows). No peptic ulceration or oesophageal varices were noted. The white material (yellow arrows) represents food particles that were washable during the procedure.

Figure 2

Contrast-enhanced CT scan of the abdomen. The axial slice shows an atrophic pancreas with multiple calcified foci (red arrow) consistent with chronic pancreatitis. Mild peripancreatic fat stranding is seen, suggesting ongoing inflammation. A, aorta; K, kidney; L, liver; S, spleen.

Figure 3

Contrast-enhanced CT scan of the abdomen. (A) Coronal and (B) axial images showing a well-defined homogeneously enhancing 2 cm×1.5 cm lesion representing the gastroduodenal artery pseudoaneurysm (red arrow) encased by the pancreas (yellow arrow) and very close to the second part of the duodenum (blue arrow). H, heart; K, kidney; L, liver; S, stomach.

Figure 4

Contrast-enhanced CT scan of the abdomen. (A) Sagittal image showing the origin of the coeliac trunk (red arrow). An incidental liver cyst is noted. (B) Note the stenosed origin of the coeliac trunk in the axial image secondary to external compression by the median arcuate ligament and the associated poststenotic dilatation (yellow arrow). A, aorta; L, liver.

Figure 5

Volume-rendered three-dimensional image showing the visceral vascular anatomy. (A) Normally, the coeliac axis (CA, thick solid arrow) trifurcates into the splenic artery (SA, long arrows), common hepatic artery (CHA, arrowhead) and left gastric artery (LGA, open black arrow). The CHA bifurcates into the gastroduodenal artery (GDA, open white arrow) and the proper hepatic artery (PHA). The PHA bifurcates into the right (small arrow) and left hepatic arteries (curved arrow). (B) Anatomical variation in the origin of the hepatic artery. The right hepatic artery (arrowheads) originates from the superior mesenteric artery (black arrow). Note the CA trifurcating into the LGA (open black arrow), SA (long arrow) and CHA. The CHA bifurcates into the left hepatic artery (curved arrow) and GDA (open white arrow). Sometimes, the whole CHA originates from the SMA (see figure 6). Images courtesy of Dr Nilgün Özbülbül.

Figure 6

Direct catheter mesenteric angiography. (A) Coeliac trunk angiogram. Note the contrast ‘blush’ indicating the gastroduodenal artery pseudoaneurysm (red arrow). (B) Superior mesenteric artery angiogram. Interestingly, the common hepatic artery (red arrow) is displayed, and the anatomical variant originates from the superior mesenteric artery (yellow arrow) instead of adopting a normal origin from the coeliac trunk (see figure 5).

Figure 7

Mesenteric embolisation. (A) Initial coiling of the afferent ‘backdoor’ feeding pancreaticoduodenal artery (red arrow). (B) Embolisation of gastroduodenal artery pseudoaneurysm with multiple small coils (red arrow). Note that a small amount of contrast is still seen within the gastroduodenal artery and the pseudoaneurysm (yellow arrows). (C) Further coiling of the feeding gastroduodenal artery (red arrow). Note that no contrast is seen extending into the pseudoaneurysm, indicating successful embolisation.