Abstract
A 25-year-old woman with no known comorbidities sought a consultation for recurrent cramping abdominal pain, lower-extremity discomfort, nausea, and vomiting. This was initially managed as acid reflux disease; however, symptom recurrence despite treatment prompted further workup. On physical examination, she was alert and independently ambulatory with the following vital signs: blood pressure 120/70, heart rate 90, respiration rate 20, and temperature 36.6°C. A head and neck examination was unremarkable. Physical examination of the chest revealed no gross deformity, adynamic precordium, regular cardiac rhythm, and a grade 3/6 holosystolic rumbling murmur best heard at the apex without heave or thrill. The abdomen was flat with an abdominal bruit at the right hemiabdomen area. There was no palpable abdominal mass or area of tenderness. Tender nodular lesions (Panel A) on the hands and feet were also noted. Pulses were full at the bilateral radial, dorsalis pedis, and posterior tibial arteries.
A porto-mesenteric duplex scan revealed a patent proximal-to-distal inferior vena cava, patent superior mesenteric, splenic, portal, and hepatic veins, and a dilated common hepatic artery with hepatopetal flow consistent with a hepatic artery aneurysm (HAA) (Panel B).
A computed tomography (CT) aortogram revealed an ovoid enhancing lesion in the porta hepatis likely causing the patient’s symptoms (Panel C). The lesion and hepatobiliary circulation were then further characterized by invasive angiography, which showed a large (3.05 cm) saccular aneurysm from the start of the hepatic artery proper (Panel D) and collateral blood vessels from the gastroduodenal artery supplying the right and left lobes of the liver. After thorough discussion with the management team, she underwent open surgical resection of the aneurysm; biopsy of the aneurysm wall showed findings consistent with polyarteritis nodosa. High-dose intravenous (IV) steroid therapy was then initiated postoperatively with good outcomes.
HAAs are rare vascular abnormalities with high rupture and morality rates.1 –5 The clinical presentation is related to size and location and may present with nonspecific symptoms that mimic more common gastrointestinal disorders.6,7 Moreover, vasculitis is an important etiology, especially among young women, and maintaining a high index of suspicion is needed to avoid missing this diagnosis.
The patient was given methylprednisolone 250 mg IV daily for 3 days and then 60 mg IV once a day thereafter. Aneurysm repair with primary end-to-end anastomosis was performed afterwards. Postoperatively, the steroid shifted to oral prednisone and the patient was discharged in a stable condition without abdominal pain or skin lesions on the fourth postoperative day.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
