Hemosuccus pancreaticus--a rare cause of gastrointestinal bleeding: diagnosis and interventional radiological therapy

Hemorrhage from the pancreatic duct, i.e. hemosuccus pancreaticus (HP), is a rare cause of gastrointestinal bleeding. Pancreatic hemosuccus is usually due to the rupture of an aneurysm of a visceral artery, most likely the splenic artery, in chronic pancreatitis. Other causes of HP are rare. We present a case of HP in a female patient with no history but with positive findings of chronic calcifying pancreatitis upon ultrasonographic investigation, computed tomography scan, and endoscopic retrograde cholangiopancreatography. With detectable fresh blood in the descending duodenum, angiography of the celiac artery revealed an aneurysm of the splenic artery as the suspected cause of intermittent bleeding from the pancreatic duct. The treatment is traditionally surgical or by interventional radiological means. This is the first case described in the literature in which interventional radiological therapy involved implantation of an uncoated metal Palmaz stent in the splenic artery. In the follow-up of 18 months no relapse of HP was observed.     

Massive lower GI hemorrhage in hemoductal pancreatitis

A patient presenting with massive lower gastrointestinal bleeding had angiographic demonstration of direct communication between the splenic artery and a dilated pancreatic duct caused by chronic pancreatitis. Previous reports in the literature of similar cases of hemoductal pancreatitis describe hemorrhage from splenic artery pseudoaneurysms.     

Hemosuccus pancreaticus: diagnosis with CT and MRI and treatment with transcatheter embolization

We report the case of a 56-year-old woman with a presyncopal episode followed by melena. A sentinel clot sign in the pancreatic duct on precontrast computed tomography and the presence of a splenic artery aneurysm on postcontrast computed tomography strongly suggested a fistula between the aneurysm and the duct, as visualized by magnetic resonance imaging. The patient was treated successfully by complete embolization of the splenic artery aneurysm. Received: 25 January 2000/Accepted: 21 February 2001     

Hemoductal pancreatitis

A case of gastrointestinal hemorrhage from a splenic artery pseudoaneurysm secondary to chronic pancreatitis with bleeding into the pancreatic duct is reported. This rare phenomenon known as hemoductal pancreatitis represents a diagnostic dilemma since bleeding is intermittent and the source of hemorrhage may not be appreciated at either angiography or surgery.     

胰源性门脉高压伴巨大脾假性动脉瘤并结肠脾区瘘致消化道大出血一例

脾假性动脉瘤所致消化道出血是一种少见的疾病。该文报道了1例43岁男性慢性胰腺炎致胰源性门脉高压伴脾假性动脉瘤并致消化道大出血患者的诊治过程。该患者既往有胰腺炎伴脾假性动脉瘤病史,因消化道大出血就诊,入院后行内镜及影像学等检查,诊断为胰源性门脉高压伴脾假性动脉瘤并结肠脾区瘘,经脾动脉栓塞术后,患者消化道出血症状消失,2个月后复查腹部CT提示原脾假性动脉瘤已基本消失。该例提示若患者既往患有胰腺炎伴脾假性动脉瘤,出现消化道出血症状时,应及时考虑是否存在动脉消化道瘘,做到及时诊治,挽救患者生命。     

Photodynamic therapy of intraductal papillary mucinous neoplasm

Intraductal papillary mucinous neoplasm (IPMN) of the main pancreatic duct is usually treated by surgical excision of the affected pancreas. Nonoperative ablative therapies have not been described. We treated IPMN of the pancreatic duct with photodynamic therapy (PDT) in a patient who was a poor operative candidate. Porfimer sodium was administered intravenously, and laser light was delivered by a diffusing catheter placed in the pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP). Imaging and biopsy findings of IPMN resolved after PDT, and symptoms also resolved. Metastatic cancer was diagnosed 2 years after PDT had been initiated. Pancreatic PDT was well tolerated in this case, and may be a therapeutic option for selected patients with IPMN of the main pancreatic duct.     

Co-occurrence of IPMN and malignant IPNB complicated by a pancreatobiliary fistula: A case report and review of the literature

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB) is pathologically similar to intraductal papillary mucinous neoplasm(IPMN). However, there are several significant differences between them. The rate of IPMN associated with extrapancreatic malignancies has been reported to range from 10%-40%, and it may occasionally be complicated with the presence of fistulas. IPMN associated with malignant IPNB is extremely rare and only nine cases have been reported in the literature.CASE SUMMARY We report a 52-year-old man who presented with recurrent cholangitis for nine months. Computed tomography and magnetic resonance cholangiopancreatography showed the common bile duct stricture with dilated pancreatobiliary duct without other abnormal findings. The underlying pathogenesis could not be identified based on the radiologic images. Endoscopic retrograde cholangiopancreatography revealed a pancreatobiliary fistula with dilated main pancreatic duct, biliary stricture with dilated biliary tree, and mucus discharge from the enlarged orifice of the major papilla. The patient underwent SpyGlass cholangiopancreatoscopy due to a suspected mucin-producing biliary neoplasm and indeterminate main pancreatic duct dilatation. Multiple papillary growing neoplasms with vascular images, with the extent of lesions spreading in the biliopancreatic ductal lumens, were identified by SpyGlass. In addition, the presence of a pancreatobiliary fistula was also identified. The patient was diagnosed as having benign IPMN and malignant IPNB with focal invasion by postoperative pathology. Furthermore, varying histological subtypes were present in both IPMN and IPNB. Pylorus-preserving pancreaticoduodenectomy was performed on the patient with excellent results during the 52 month followup period.CONCLUSION We deemed that pancreatography and SpyGlass allowed for an efficient diagnosis of IPMN with pancreatobiliary fistula, whereas the etiology could not be identified by radiologic imaging.     

脾动脉瘤临床诊治分析(附12例报告)

目的:总结12例脾动脉瘤的临床诊断治疗经验。方法:对2001年1月至2007年6月华西医院诊治的12例脾动脉瘤作回顾性分析。结果:12例脾动脉瘤中伴动脉粥样硬化3例,门脉高压症2例,慢性胰腺炎2例,胰腺损伤后2例,胰尾肿瘤1例;其中自发性破裂大出血2例。11例经彩色多普勒、CT、磁共振血管造影(MRA)、选择性内脏动脉造影确诊,1例依靠手术探查确诊,没有1例能单独依靠临床表现明确诊断。本组中行动脉瘤切除加脾切除4例,单纯动脉瘤切除1例,动脉瘤近远端动脉结扎1例,动脉瘤体伴胰体尾部切除加脾切除1例,动脉介入栓塞1例,死亡2例。结论:脾动脉瘤一般起病隐匿,临床症状很少具有特征性表现,选择性内脏动脉造影最具有诊断价值。一旦确诊应及时根据病情选择微创介入栓塞治疗或尽早手术。     

胰腺导管内乳头状黏液性肿瘤的MSCT和MRCP诊断

目的 探讨胰腺导管内乳头状黏液性肿瘤 （IPMN）的MSCT和MRCP影像学表现.方法 对26例经内镜或手术病理证实的IPMT患者的CT和MRCP表现进行回顾性分析.结果 分支胰管型IPMN12 例,表现为单发囊性病变或葡萄串样多发囊性病变伴腔内分隔或结节样突起;主胰管型 IPMN 5 例,表现为主胰管扩张伴管壁结节样突起;混合型IPMN 9例,表现为主胰管扩张和囊性病变合并存在.9例手术病理结果为腺瘤1例,交界性肿瘤2例,腺癌6例.结论 MSCT和MRCP对发现和诊断胰腺 IPMN具有较高价值.     

胰腺导管内乳头状黏液性肿瘤的MSCT征象

目的探讨胰腺导管内乳头状黏液性肿瘤(IPMN)的MSCT特点。方法回顾性分析27例经病理证实的IPMN的MSCT表现。所有患者均接受16层或64层CT平扫及增强检查,其中7例接受ERCP检查。结果27例IPMN中,主胰管型11例,包括2例交界性肿瘤,4例原位癌,5例腺癌;CT表现为胰腺不同程度萎缩,主胰管扩张,8例内部可见壁结节,1例见多发斑块状钙化。分支胰管型9例,包括腺瘤和交界性肿瘤各3例,1例原位癌,2例腺癌;其中7例位于胰头部,表现为与主胰管相通的囊性病灶,内见分隔和乳头状壁结节,呈"葡萄串"样,1例可见点状钙化;2例位于胰尾部,呈类圆形囊性病灶,增强无强化。混合型7例,包括交界性肿瘤和腺癌各3例,原位癌1例,表现为主胰管及分支胰管扩张伴腔内壁结节,3例病变内可见不同程度钙化。7例接受ERCP,其中5例明确显示囊性病灶与主胰管相通。结论 IPMN的MSCT表现具有一定特征。MSCT结合ERCP检查有助于术前准确诊断。     

MSCT后处理技术在诊断胰腺导管内乳头状黏液瘤中的应用

目的 探讨MSCT后处理技术在胰腺导管内乳头状黏液瘤(IPMN)中的诊断价值.方法 对18例经手术病理或超声内镜引导下细针穿刺证实的IPMN患者的临床、病理及MSCT检查资料进行回顾性分析,对MSCT双期增强扫描的原始数据均行MPR、MinIP及CPR,观察病变本身及其与胰管、周围结构的关系.结果 18例IPMN患者中,病变与扩张胰管相通18例(18/18,100%),胰管扩张 >1.0 cm 7例(7/18,38.89%),囊性病变17例(17/18,94.44%),囊实性病变1例(1/18,5.56%).主胰管型6例(6/18,33.33%)、分支胰管型9例(9/18,50.00%)、混合型3例(3/18,16.67%).MPR图像能清晰显示IPMN病变的大小、边界、有无强化的壁结节,也可较好显示病变与扩张胰管间的关系以及病变与周围结构之间的关系;MinIP图像在显示扩张胰管的全貌及病变与扩张胰管间关系等方面优于MPR图像及CPR图像;CPR图像有助于显示主胰管扩张的全貌.结论 利用MSCT多种后处理技术可整体显示病变、扩张胰管以及周围结构,在IPMN诊断方面具有重要价值.     

Laparoscopic resection for splenic artery aneurysm using the lateral approach: Report of two cases

We report two cases of successful laparoscopic surgery for splenic artery aneurysm. In case 1, a 59‐year‐old man who had hypertension was admitted to the hospital with complaints of slight back pain. CT scan showed a winding splenic artery and an aneurysm behind the pancreas body. In case 2, a 71‐year‐old woman with hypertension consulted us and was diagnosed with splenic artery aneurysm. Her aneurysm increased from 1.2 mm to 20 mm at the 1‐year follow‐up. In both cases, we performed laparoscopic splenectomy, using the left lateral approach, to resect the aneurysm. Splenectomy was performed after the spleen had changed color. The operating times were 210 and 259 min, respectively and the bleeding was 60 and 100 mL, respectively. The postoperative course was uneventful. By using the lateral approach from the left side, we were able to precisely resect the splenic artery aneurysm under a stable laparoscopic view.     

Detection of anomalous splenic artery aneurysms with three-dimensional contrast-enhanced MR angiography

Background

Aneurysms of the splenic artery which arise anomalously from the superior mesenteric artery are extremely rare but clinically important because of their life-threatening hemorrhage. Diagnostic imaging plays an important role in the diagnosis and conducting treatment strategy. The aim of this study was to evaluate the detection of anomalous splenic artery aneurysms with 3D contrast-enhanced MR angiography.

Methods

3D contrast-enhanced MR angiography was performed in six patients with anomalous splenic artery aneurysms.

Results

The mean diameter of six aneurysms was 3.9 cm. All of them were saccular and located at the origin of the splenic artery that arose anomalously from the root of the superior mesenteric artery. 3D contrast-enhanced MR angiography clearly demonstrated the aneurysm’s location, size, morphology, visceral arterial variations, and was superior to DSA in three-dimensional display of the aneurysm and its relationship with surrounding vessels and organs. Two patients underwent open vascular surgery and three endovascular procedure.

Conclusion

3D contrast-enhanced MR angiography is a noninvasive and accurate technique for diagnosis of anomalous splenic artery aneurysms. Its 3D anatomic information is very helpful for treatment planning. It can be used as one of the first choice examinations for anomalous splenic artery aneurysms.     

增强CT联合纹理分析对于胰腺导管内乳头状黏液性肿瘤恶性潜能的预测价值

目的:探讨增强CT图像的纹理分析对胰腺导管内乳头状黏液性肿瘤(Intraductal papillary mucinous neoplasm,IPMN)恶性潜能的预测价值.方法:回顾性收集2010年1月-2019年12月经手术病理证实为分支胰管型IPMN(Branch duct IPMN,BD-IPMN)或混合型IPM...     

Arteriovenous fistula of the thyroid gland associated with spontaneous bleeding from a flow-induced aneurysm of the inferior thyroid artery.

A case of acute, spontaneous cervical hemorrhage caused by a ruptured aneurysm of the inferior thyroid artery is described. This lesion was accompanied by an arteriovenous fistula within the thyroid gland that caused a flow-induced aneurysm. Diagnosis and treatment were successfully performed by selective angiography with endovascular occlusion and embolization. Both diagnostic and therapeutic management are discussed, and the related literature is reviewed. To our knowledge, this is the first reported case of an aneurysm of a thyroid artery in conjunction with an intraparenchymatous arteriovenous fistula of the thyroid gland.     

Completely thrombosed splenic artery aneurysm mimicking cystic pancreatic mass: Computed tomographic findings

A case of a completely thrombosed aneurysm of the splenic artery is reported. The central lumen of the aneurysm was not enhanced on computed tomography (CT); therefore, a cystic pancreatic mass could not be excluded. This entity should be considered in the differential diagnosis when a cystic peripancreatic mass with a calcified rim is detected on CT.     

Laparoscopic surgery for the treatment of a ruptured aneurysm of the right gastric artery: a case report

Laparoscopic surgery for the treatment of a ruptured visceral artery aneurysm is recognized as a challenging procedure. Here, we describe our experience with laparoscopic surgery to treat a ruptured aneurysm of the right gastric artery. A 72‐year‐old woman was diagnosed with intra‐abdominal hemorrhage caused by a ruptured aneurysm of the right gastric artery. Transcatheter arterial embolization failed because the right gastric artery could not be cannulated. Therefore, we performed laparoscopic surgery. Using laparoscopy, we detected that the bleeding from the aneurysm had ceased; thus, the planned procedure was successful. The operative time and intraoperative blood loss were 100 min and 5 mL, respectively. The patient was discharged 7 days after surgery. Laparoscopic surgery after the failure of transcatheter arterial embolization is a suitable and safe procedure for ruptured visceral artery aneurysms, provided the circulatory dynamics are stable as a result of the temporary cessation of bleeding from the ruptured aneurysm.     

胰腺导管内乳头状黏液性肿瘤的影像学诊断进展

胰腺导管内乳头状黏液性肿瘤是一种位于扩张的主胰管和(或)分支胰管内、伴大量黏液分泌的肿瘤,易与慢性胰腺炎或胰腺囊腺瘤混淆而延误诊断.本文就国内外近年来关于胰腺导管内乳头状黏液性肿瘤的临床病理学及影像学研究进展进行综述,评价不同影像技术(US、CT、MRCP、ERCP)在胰腺导管内乳头状黏液性肿瘤诊断中的作用.     

Management of the late effects of disconnected pancreatic duct syndrome: A case report

BACKGROUND There have been few reports about the late effects of disconnected pancreatic duct syndrome(DPDS). Although few reports have described the recurrence interval of pancreatitis, it might be rare for recurrence to occur more than 5 years later.Herein, we describe a case of recurrence in an 81-year-old man after the treatment of walled-off necrosis(WON) with pancreatic transection 7 years ago.CASE SUMMARY An 81-year-old man visited our hospital with chief complaints of fever and abdominal pain 7 years after the onset of WON due to severe necrotic pancreatitis. His medical history included an abdominal aortic aneurysm(AAA),hypertension, dyslipidemia, and chronic kidney disease. Computed tomography(CT) scan showed that the pancreatic fluid collection(PFC) had spread to the aorta with inflammation surrounding it, and CT findings suggested that bleeding occurred from the vasodilation due to splenic vein occlusion. First, we attempted to perform transpapillary drainage because of venous dilation around the residual stomach and the PFC. However, pancreatic duct drainage failed because of complete main pancreatic duct disruption. Second, we performed endoscopic ultrasound-guided drainage. After transmural drainage, the inflammation improved and stenting for the AAA was performed successfully. The inflammation was resolved, and he has been free from infection for more than 2 years after the procedure.CONCLUSION This case highlights the importance of continued follow-up of patients for recurrence after the treatment of WON with pancreatic transection.     

Pancreatica magna aneurysm: rupture into the pancreatic duct

A 49-year-old black man had rupture of a pancreatica magna aneurysm into the pancreatic duct as an inflammatory consequence of chronic pancreatitis and pancreatic pseudocyst. It is the ninth reported case of splenic arterial branch rupture due to chronic pancreatitis and the seventh reported case due to chronic pancreatitis associated with pancreatic pseudocyst, and is presented to emphasize its importance as a possible cause of gastrointestinal bleeding.