Hospitalist University of Iowa hospital and clinics, United States
Introduction: Splenic artery is the most common site of visceral aneurysms which requires a high index of suspicion due to high mortality in case of rupture. We present a rare case of splenic artery aneurysm (SAP) in association with hereditary pancreatitis (HP) and with bleeding in the pancreatic duct leading to Hemosuccus pancreaticus (HP).
Description: A 44-year-old female with a history of HP along with splenic and portal vein thrombosis (no longer on anticoagulation), presented with hematemesis and hematochezia. Initial labs revealed a hemoglobin (Hb) of 7.2 and hematocrit of 25. IV Pantoprazole was initiated, and Gastroenterology (GI) was consulted. Endoscopy/Colonoscopy ruled out active or recent bleeding sources, while video capsule endoscopy identified oozing blood spots at various locations in the small bowel. The patient's Hb continued to drop, necessitating frequent blood transfusions (BTs). Tagged RBC scan and double balloon study indicated active bleeding in the duodenum and proximal jejunum, possibly linked to underlying portal hypertension (PH). Liver biopsy revealed subtle findings consistent with PH, and abdominal Doppler ultrasound showed no thrombus in the portal or splenic vein. Workup for recurrent venous thromboembolism yielded negative results for antiphospholipid antibodies. Echocardiogram showed no vegetations or intracardiac shunting, and venous duplex ruled out DVT. Given recurrent GI bleeding, dropping Hb, and frequent BTs, anticoagulation was not initiated. A CTA revealed a 1.3 cm SAP bleeding into the pancreatic duct. Coil embolization successfully treated the SAP. Hb remained stable, and the patient received a heparin drip for pulmonary embolism before being transitioned to apixaban. Subsequently, the patient was discharged home.
Discussion: SAP is a rare complication of HP which itself is rare phenomenon. Most common causes of SAP are attributed to chronic pancreatitis (52%), trauma (29%), iatrogenic postoperative cause (3%), and rarely gastric ulcer disease (2%). Clinical manifestations being Abdominal pain (29.5%), melena (26.2%), Hemorrhage into pancreatic duct (20.3%), hematemesis after abdominal pain (14.3%). All SAPs should be treated promptly due to their risk of rupture and fistulization. Treatment options for SAPs include endovascular and surgical approaches.
