A Rare Cause of Upper Gastrointestinal Bleeding
Article Outline
- Answer to the Clinical Challenges and Images in GI Question: Image 1: Right Gastric Artery Aneurysm Complicating as Upper Gastrointestinal Bleeding
- References
- Copyright
Question: An 84-year-old man with a past medical history of prostate cancer and duodenal ulcer presented with right upper quadrant pain, hematochezia, and postural hypotension. Physical examination disclosed pale conjunctiva, abdominal distension, and right upper quadrant tenderness. Laboratory tests were unremarkable except for anemia (hemoglobin, 9.6 mg/dL). He underwent an upper gastrointestinal endoscopy, which demonstrated an ulcer at the first part of the duodenum with a protruding mass in the base but no active bleeding (Figure A). In the next 2 days, intermittent episodes of tarry stools continued. He also had the development of hypotension which responded to fluid resuscitation. His hemoglobin fell to 6.2 mg/dL. On repeat endoscopy, active bleeding from the same lesion was found. Hemostasis was obtained by clipping and epinephrine injection. Abdominal computed tomography was performed (Figure B).
What is the diagnosis?
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Answer to the Clinical Challenges and Images in GI Question: Image 1: Right Gastric Artery Aneurysm Complicating as Upper Gastrointestinal Bleeding
Abdominal computed tomography with intravenous contrast materials showed an abnormal outpouching lesion from the right gastric artery (black arrow) with metallic clips retention at its tip (white arrows; Figure B). Angiography demonstrated an aneurysm in the distal part of right gastric artery (black arrow) with 2 metallic clips nearby (white arrows; Figure C). Selective embolization with metallic coils was successfully performed. After that, his gastrointestinal bleeding stopped.
Visceral artery aneurysms are rare but potentially lethal. They occur most commonly in the splenic artery (60%), hepatic artery (20%), superior mesenteric artery (5%), and celiac trunk (4%).1 They may be caused by an adjacent inflammatory process, arteriosclerosis, trauma, autoimmune vascular disease, and degeneration.2 Patients may present with vague abdominal discomfort and life threatening intra-abdominal or gastrointestinal bleeding because of rupture. Aneurysms of the right gastric artery are extremely rare, so that there are only a few individual case reports.3 In our case, right gastric artery aneurysm may relate to a long-term history of duodenal ulcer and senile degeneration. Computed tomography is useful for accurately diagnosing the aneurysm, whereas angiography can provide better characterization and localization of the aneurysm as well as additionally therapeutic advantage such as embolization.1 Of interest is that, in this case, endoscopic clipping was performed for hemostasis and fluoroscopic localization to guide embolization therapy. It has been suggested that operative intervention is reserved for complicated cases or in patients with failed angiographic treatment.1 Our patient underwent successful angioembolization for right gastric aneurysm with gradual return of hemoglobin by the time of hospital discharge.
References
Conflicts of interest The authors disclose no conflicts.
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PII: S0016-5085(09)01967-2
doi:10.1053/j.gastro.2009.09.070
© 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.
