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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
Case of the Month
Not Just a Pseudocyst: Gastroduodenal Artery Pseudoaneurysm in Chronic Pancreatitis
Not Just a Pseudocyst: Gastroduodenal Artery Pseudoaneurysm in Chronic Pancreatitis
Contributed by : Nishant Tembhekar
Contributed by : Nishant Tembhekar
Introduction :
Introduction :
Chronic pancreatitis is associated with a spectrum of vascular complications, among which visceral artery pseudoaneurysms are rare but potentially life-threatening. These pseudoaneurysms arise from enzymatic digestion and inflammatory weakening of the arterial wall, most commonly involving the splenic artery. Gastroduodenal artery (GDA) pseudoaneurysms are less frequent but carry a particularly high risk of rupture and massive haemorrhage. Early recognition using appropriate imaging modalities and prompt endovascular management are essential to reduce morbidity and mortality.
Chronic pancreatitis is associated with a spectrum of vascular complications, among which visceral artery pseudoaneurysms are rare but potentially life-threatening. These pseudoaneurysms arise from enzymatic digestion and inflammatory weakening of the arterial wall, most commonly involving the splenic artery. Gastroduodenal artery (GDA) pseudoaneurysms are less frequent but carry a particularly high risk of rupture and massive haemorrhage. Early recognition using appropriate imaging modalities and prompt endovascular management are essential to reduce morbidity and mortality.
Case presentation:
Case presentation:
A 34-year-old man known to have chronic pancreatitis presented with persistent epigastric pain for eight days. The pain had been progressively increasing in intensity. There was no history of hematemesis, melena, or trauma. Clinical examination revealed epigastric tenderness without signs of peritonitis. Laboratory investigations showed mildly elevated serum amylase and lipase levels, along with reduced haemoglobin levels.
A 34-year-old man known to have chronic pancreatitis presented with persistent epigastric pain for eight days. The pain had been progressively increasing in intensity. There was no history of hematemesis, melena, or trauma. Clinical examination revealed epigastric tenderness without signs of peritonitis. Laboratory investigations showed mildly elevated serum amylase and lipase levels, along with reduced haemoglobin levels.
Given the persistent pain against the background of chronic pancreatitis, a contrast-enhanced CT (CECT) of the abdomen was performed.
Given the persistent pain against the background of chronic pancreatitis, a contrast-enhanced CT (CECT) of the abdomen was performed.
Radiological findings
Radiological findings
The contrast-enhanced CT of the abdomen demonstrated features of chronic calcific pancreatitis, including pancreatic parenchymal atrophy, intraductal calcifications, and main pancreatic duct dilatation up to 11.2 mm (Figure 1). The portal vein is replaced by multiple collaterals,indicating a portal cavernoma.
The contrast-enhanced CT of the abdomen demonstrated features of chronic calcific pancreatitis, including pancreatic parenchymal atrophy, intraductal calcifications, and main pancreatic duct dilatation up to 11.2 mm (Figure 1). The portal vein is replaced by multiple collaterals,indicating a portal cavernoma.
Fig 1 Contrast-enhanced CT of the abdomen shows features of chronic calcific pancreatitis, including pancreatic parenchymal atrophy (white arrow), intraductal calcifications (black arrow), and dilated main pancreatic duct up to 11.2 mm (yellow arrow).
A large thin-walled pseudocyst measuring 5.6 × 8.5 × 8.6 cm is seen posterior to the pancreatic head (Figure 2a). Within the pseudocyst, ia a well-defined enhancing lesion measuring 5.7 × 5.1 × 7.3 cm that shows progressive enhancement with attenuation similar to venous collaterals (Figure 2b). It has a narrow-necked communication (~3.7 mm). The enhancement pattern does not match that of arteries, likely due to partial thrombosis or slow flow through a narrow neck, posing a diagnostic challenge.
A large thin-walled pseudocyst measuring 5.6 × 8.5 × 8.6 cm is seen posterior to the pancreatic head (Figure 2a). Within the pseudocyst, ia a well-defined enhancing lesion measuring 5.7 × 5.1 × 7.3 cm that shows progressive enhancement with attenuation similar to venous collaterals (Figure 2b). It has a narrow-necked communication (~3.7 mm). The enhancement pattern does not match that of arteries, likely due to partial thrombosis or slow flow through a narrow neck, posing a diagnostic challenge.
Fig 2a. Axial CECT image shows a large thin-walled cystic lesion posterior to the pancreatic head (horizontal arrow), measuring 5.6 × 8.5 × 8.6 cm, with internal enhancing lesion (arrow) suggestive of vascular origin.
Fig 2b. Coronal CECT image demonstrates progressive enhancement of the internal lesion within the pseudocyst (black arrow), with attenuation similar to venous collaterals (white arrow).
Ultrasonography
Ultrasonography
Targeted ultrasonography revealed a cystic-appearing lesion adjacent to the pancreatic head (Figure 3a). Colour Doppler evaluation demonstrated the characteristic “yin–yang” sign with an arterial waveform (peak systolic velocity ~20 cm/s), indicating turbulent bidirectional blood flow within the lesion (Figure 3b). These findings confirmed the vascular nature of the lesion and established the diagnosis of a pseudoaneurysm rather than a pseudocyst.
Targeted ultrasonography revealed a cystic-appearing lesion adjacent to the pancreatic head (Figure 3a). Colour Doppler evaluation demonstrated the characteristic “yin–yang” sign with an arterial waveform (peak systolic velocity ~20 cm/s), indicating turbulent bidirectional blood flow within the lesion (Figure 3b). These findings confirmed the vascular nature of the lesion and established the diagnosis of a pseudoaneurysm rather than a pseudocyst.
Fig 3a Grayscale ultrasonography shows a cystic-appearing lesion adjacent to the pancreatic head (white arrow).
Fig 3b Colour Doppler ultrasonography demonstrates the characteristic “yin–yang” sign (yellow arrow) with turbulent bidirectional arterial flow within the lesion, confirming the diagnosis of a pseudoaneurysm.
Management:
Management:
Digital subtraction angiography confirmed a pseudoaneurysm arising from the gastroduodenal artery (Figure 4a). Selective catheterization of the GDA was performed, followed by coil embolization of the pseudoaneurysm and the parent artery using multiple detachable coils. Post-embolization angiography demonstrated complete exclusion of the pseudoaneurysm with no residual filling. Flow in the parent artery was normal. (Figure 4b).
Digital subtraction angiography confirmed a pseudoaneurysm arising from the gastroduodenal artery (Figure 4a). Selective catheterization of the GDA was performed, followed by coil embolization of the pseudoaneurysm and the parent artery using multiple detachable coils. Post-embolization angiography demonstrated complete exclusion of the pseudoaneurysm with no residual filling. Flow in the parent artery was normal. (Figure 4b).
The patient had an uneventful post-procedural course and was advised follow up.
The patient had an uneventful post-procedural course and was advised follow up.
Figure 4a Angiography shows a pseudoaneurysm arising from the gastroduodenal artery (white arrow) prior to intervention.
Figure 4b. Post-embolizationangiogram demonstrates complete exclusion of the pseudoaneurysm with coils in situ (yellow arrow) and preserved flow in adjacent major vessels.
Timeline:
Timeline:
Discussion
Discussion
Visceral artery pseudoaneurysms are rare but potentially fatal complications of chronic pancreatitis and are associated with a high risk of rupture and mortality if left untreated [1]. These pseudoaneurysms develop due to enzymatic and inflammatory erosion of the arterial wall, most commonly involving the splenic artery, while gastroduodenal artery involvement is relatively uncommon [2].
Visceral artery pseudoaneurysms are rare but potentially fatal complications of chronic pancreatitis and are associated with a high risk of rupture and mortality if left untreated [1]. These pseudoaneurysms develop due to enzymatic and inflammatory erosion of the arterial wall, most commonly involving the splenic artery, while gastroduodenal artery involvement is relatively uncommon [2].
Atypical imaging appearances may occur in cases of partial thrombosis or slow intraluminal flow, resulting in misleading enhancement patterns on CT and potential misdiagnosis as a pancreatic pseudocyst [3]. In such scenarios, colour Doppler ultrasonography serves as a critical adjunct. The presence of a characteristic yin–yang sign with bidirectional arterial flow is highly suggestive of a pseudoaneurysm and helps distinguish it from non-vascular cystic lesions [4].
Atypical imaging appearances may occur in cases of partial thrombosis or slow intraluminal flow, resulting in misleading enhancement patterns on CT and potential misdiagnosis as a pancreatic pseudocyst [3]. In such scenarios, colour Doppler ultrasonography serves as a critical adjunct. The presence of a characteristic yin–yang sign with bidirectional arterial flow is highly suggestive of a pseudoaneurysm and helps distinguish it from non-vascular cystic lesions [4].
Endovascular therapy is currently the preferred treatment modality due to its minimally invasive nature and high technical success rate. Coil embolization effectively excludes the pseudoaneurysm from circulation while preserving flow in adjacent vessels. Surgical intervention is reserved for cases of failed embolization, rupture, or hemodynamic instability [5].
Endovascular therapy is currently the preferred treatment modality due to its minimally invasive nature and high technical success rate. Coil embolization effectively excludes the pseudoaneurysm from circulation while preserving flow in adjacent vessels. Surgical intervention is reserved for cases of failed embolization, rupture, or hemodynamic instability [5].
Conclusion
Conclusion
In patients with chronic pancreatitis, a peripancreatic cystic-appearing lesion should be carefully evaluated to rule out a pseudoaneurysm using Doppler ultrasound and if warranted, angiography. Timely endovascular treatment is critical to preventing . astrophic haemorrhage.
In patients with chronic pancreatitis, a peripancreatic cystic-appearing lesion should be carefully evaluated to rule out a pseudoaneurysm using Doppler ultrasound and if warranted, angiography. Timely endovascular treatment is critical to preventing . astrophic haemorrhage.
References:
References:
1. Boudghène F, L’Hermine C, Bigot JM. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol. 1993;4(4):551–558.
1. Boudghène F, L’Hermine C, Bigot JM. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol. 1993;4(4):551–558.
2. Safi F, Beger HG. Pseudoaneurysms in chronic pancreatitis. Int J Pancreatol. 1992;12(1):13–20.
2. Safi F, Beger HG. Pseudoaneurysms in chronic pancreatitis. Int J Pancreatol. 1992;12(1):13–20.
3. Mortelé KJ, Mergo PJ, Taylor HM, Ernst MD, Ros PR. Peripancreatic vascular abnormalities complicating pancreatitis: CT findings. Eur J Radiol. 2004;52(1):67–72.
3. Mortelé KJ, Mergo PJ, Taylor HM, Ernst MD, Ros PR. Peripancreatic vascular abnormalities complicating pancreatitis: CT findings. Eur J Radiol. 2004;52(1):67–72.
4. Dörffel Y, Wruck T, Rückert RI, et al. Vascular complications in pancreatitis assessed by color duplex ultrasonography. Pancreas. 2000;21(2):126–133.
4. Dörffel Y, Wruck T, Rückert RI, et al. Vascular complications in pancreatitis assessed by color duplex ultrasonography. Pancreas. 2000;21(2):126–133.
5. Udd M, Leppäniemi A, Bidel S, Keto P, Roth WD, Haapiainen R. Treatment of bleeding pseudoaneurysms in chronic pancreatitis. World J Surg. 2007;31(3):504–510.
5. Udd M, Leppäniemi A, Bidel S, Keto P, Roth WD, Haapiainen R. Treatment of bleeding pseudoaneurysms in chronic pancreatitis. World J Surg. 2007;31(3):504–510.
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