Abstract
Pseudoaneurysms are uncommon but their rupture and bleeding can lead to serious complications and be fatal. We present here a case of a man in his late 70s who was transferred to our hospital with persistent gastrointestinal bleeding. One month prior to his admission, he had undergone surgery for a fracture to his left knee. Endoscopic examination found pulsating blood vessels on a duodenal ulcer, which suddenly ruptured and caused significant bleeding. Immediate endoscopic haemostasis was administered and the bleeding decreased. Considering the high rate of rebleeding that may occur with a pseudoaneurysm, the patient underwent interventional radiology that culminated in a diagnosis of a pseudoaneurysm originating from gastroduodenal artery (GDA); successful embolization was achieved. Tests showed that the patient had Helicobacter pylori infection. We hypothesised that the H. pylori infection had led to the occurrence of the duodenal bulb ulcer, and the patient’s left knee fracture and surgery a month previously had contributed to this predisposition for a pseudoaneurysm.
Background
Pseudoaneurysm refers to tearing or perforation of the arterial wall, causing blood to flow out of the opening and be enveloped by adjacent tissues of the artery, forming a hematoma. They typically arise from iatrogenic injuries (e.g., catheter-based interventions) or erosions such as trauma or infection.1,2 Femoral, aortic and visceral pseudoaneurysms are the most common types. 2 While uncommon, they can be life-threatening if not treated promptly due to rupture and bleeding. 3 Indeed, early identification and adequate therapeutic intervention are critical for a good outcome. In recent years, angiography has emerged as an effective treatment option to prevent or stop bleeding, but surgery is still regarded as the standard measure if angiography has failed.2,4 We present here, a case where gastrointestinal bleeding resulting from rupture of a duodenal bulb pseudoaneurysm was located during endoscopy and successfully treated with endoscopic clips which permitted follow-up interventional radiology.
Case Report
A man in his late 70s, with a two-day history of hematemesis and melena, was admitted to our emergency room. He had initially presented at a local hospital with anaemia (haemoglobin [Hb], 51 g/l), and an endoscopy had shown the presence of a duodenal ulcer. The patient had been transferred to our institution for further evaluation because of gastrointestinal bleeding. A month prior to his admission, he had been diagnosed with a fracture of the left knee joint and had undergone open reduction and internal fixation of the left patellar fracture. The patient had no history of anticoagulant, non-steroidal anti-inflammatory drug (NSAID) or antiplatelet drug usage. In addition, he had no record of any prior gastroscopy or a carbon-13 or 14 (13C/14C) breath test.
On physical examination, his vital signs were as follows: temperature, 36.8°C; blood pressure (BP), 80/50 mmHg; heart rate, 110 beats per min; respiratory rate, 18 breaths per min. With the exception of pale eyelid conjunctiva, he exhibited no abnormal physical findings. Laboratory test results showed low levels of Hb (54 g/l), and a positive faecal occult blood test (Table 1). We promptly conducted a non-contrast computed tomography (CT) scan for expediency because of the patient's advanced age and limited capacity to endure prolonged examinations. The non-contrast CT scan showed the presence of an effusion surrounding the duodenal bulb and suggested the likelihood of a local ulcer.
Laboratory results on admission.
Hb, haemoglobin; RBC, red blood cells; WBC, white blood cells.
After receiving conservative care, the patient’s vital signs stabilized. Considering that the patient’s external gastroscopy findings suggested a duodenal bulb ulcer, and our non-contrast CT scan showed the presence of a duodenal bulb effusion, we postulated the presence of an ulcer. Our primary consideration for the aetiology of the upper gastrointestinal bleeding was a bleeding duodenal ulcer. Consequently, following the patient's informed consent for medical intervention, an emergency endoscopy was immediately performed and a large deep ulcer with a pulsating blood vessel on its surface was observed in the duodenal bulb (Figure 1). Repositioning of the endoscope to the stomach to obtain a better view of the bleeding ulcer in the duodenal bulb, showed blood flowing continuously from the ulcer. Our diagnosis was upper gastrointestinal bleeding resulting from rupture of a duodenal bulb pseudoaneurysm. Achieving endoscopic haemostasis was difficult, because of the ongoing haemorrhage and the restricted view, and so the only treatment option was multiple endoscopic clips. The bleeding from the pulsating blood vessel gradually decreased. Considering the high rate of rebleeding that may occur with a pseudoaneurysm, celiac artery angiography was performed and a diagnosis of a pseudoaneurysm of the gastroduodenal artery (GDA) was confirmed (Figure 2). Micro coils and gelatine sponges were used to embolize the branch of the GDA and subsequent angiography confirmed successful treatment and absence of the pseudoaneurysm.
The duodenal bulb. The central white area is an ulcer with a mucosal protrusion within it which is considered to be a pseudoaneurysm.
(a) Mesenteric angiography confirmed the rupture of a branch of the gastroduodenal artery (GDA), with the contrast agent entering the duodenum (white arrow) and (b) Following embolization, there was no leakage of contrast agent during the second angiography.
Following surgery, the patient reported no significant discomfort after eating, and his Hb levels increased to 90 g/l. He was discharged from hospital 10 days later without any signs of bleeding or intestinal ischemia. Gastroscopic examination had shown the presence of Helicobacter pylori infection and so, a month later, at the outpatient clinic, he received treatment for the bacteria.
The reporting of this study conforms to CARE guidelines. 5 Written informed consent was obtained from the patient to publish his anonymised data. The study received an ethical exemption from the Ethics Committee of Ningbo Medical Center Lihuili Hospital (approval number: KY2023ML010).
Discussion
Pseudoaneurysms are uncommon but their rupture and bleeding can lead to serious complications and be life-threatening. 3 Multiple aetiologies have been suggested including, atherosclerosis, trauma, surgery, pancreatitis, infection, inflammation, tumours, collagen vascular disease and congenital abnormalities.2,3,6 Iatrogenic factors, such as arterial injury caused by surgery, are considered one of the main risk factors. 7 In this present case, we hypothesised that the H. pylori infection had led to the occurrence of the duodenal bulb ulcer, and the patient’s left knee fracture a month previously had been a major predisposing factor for the pseudoaneurysm. The pseudoaneurysm may have arisen as a complication of inflammation associated with the peptic ulcer. Since, the duodenal wall is thin and adjacent to the GDA, the erosive, duodenal ulcer has the potential to invade the GDA and cause a pseudoaneurysm. 8
Angiography has emerged as a gold standard for diagnosis and an effective treatment when a gastroduodenal pseudoaneurysm is suspected. 9 Contrast-enhanced CT is an excellent non-invasive modality to demonstrate the features of a pseudoaneurysm, but its sensitivity is lower than that of angiography (67% vs. 100%). 8 The multiphase acquisitions of multidetector computed tomography angiography (MDCTA) allows a detailed assessment of the vascular anatomy and, is considered by some investigators as the ‘new’ gold-standard, alongside angiography.10,11 In our case, the patient was too weak to tolerate a contrast-enhanced CT, and so celiac artery angiography was used to identify the pseudoaneurysm and embolize it successfully.
Endoscopic haemostasis is widely used to address duodenal ulcer bleeding.12,13 Nevertheless, managing bleeding in patients with gastroduodenal artery pseudoaneurysms can be challenging and risky. This is due in part to the narrowness of the duodenal bulb. 8,12 In addition, it is difficult to operate when the ulcer is bleeding and the vision is poor. Also, the task of controlling the bleeding by the GDA by hemoclipping or thermocoagulation can be difficult, even when using an over-the-scope clip.12–14 Despite successful endoscopic haemostasis, pseudoaneurysms are associated with a high rate of future re-bleeding. 15 Consequently, selective transcatheter embolization has become the preferred treatment for pseudoaneurysms favoured over surgery, as it is less invasive, offers a greater efficacy rate (67–100%), and a low rate of morbidity and mortality.9,15 In our case, the patient suffered rupture and bleeding of the pseudoaneurysm during endoscopy, which may have been due to fluctuations in BP which led to a sudden increase in blood vessel pressure. Fortunately, the bleeding was controlled by means of endoscopic clip haemostasis, which permitted follow-up interventional radiology.
In conclusion, pseudoaneurysm can rupture causing significant bleeding that may not be immediately obvious which can lead to death. Patients often have unstable vital signs before intervention or surgery, and medical treatment may not be effective. 3 Timely and effective endoscopic haemostasis is necessary to avoid adverse complications from the haemorrhage and rupture.
