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Wang H, Tan YQ, Han P, Xu AH, Mu HL, Zhu Z, Ma L, Liu M, Xie HP. Left inferior phrenic arterial malformation mimicking gastric varices: A case report and review of literature. World J Gastrointest Surg 2024; 16:3057-3064. [PMID: 39351559 PMCID: PMC11438799 DOI: 10.4240/wjgs.v16.i9.3057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 08/08/2024] [Accepted: 08/16/2024] [Indexed: 09/18/2024] Open
Abstract
BACKGROUND Gastric submucosal arterial dilation resulting from splenic artery occlusion represents an exceedingly rare etiology of acute upper gastrointestinal bleeding (UGIB). Although endoscopy is a widely utilized diagnostic and therapeutic modality for gastrointestinal bleeding, it has limitations in detecting arterial abnormalities. CASE SUMMARY This report presents a rare case of massive UGIB in a 57-year-old male with a tortuous left inferior phrenic artery accompanied by splenic artery occlusion. "Gastric varices" was identified during the patient's endoscopy one year before hemorrhage. Despite initial hemostasis by endoscopic clipping, the patient experienced massive rebleeding after one month, requiring intervention with transcatheter arterial embolization (TAE) to achieve hemostasis. CONCLUSION This is the first case to report UGIB due to a tortuous left inferior phrenic artery. This case highlights the limitations of endoscopy in identifying arterial abnormalities and emphasizes the potential of TAE as a viable alternative for the management of arterial bleeding in the gastrointestinal tract.
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Affiliation(s)
- Han Wang
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Yi-Qing Tan
- Department of Radiology, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan University, Wuhan 430063, Hubei Province, China
| | - Ping Han
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - An-Hui Xu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Han-Lin Mu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Zhe Zhu
- Department of Pathology and Cell Biology, Columbia University Irving medical center, New York-Presbyterian Hospital, New York, NY 10065, United States
| | - Li Ma
- Department of Gastroenterology, Jianli People's Hospital, Jianli 433300, Hubei Province, China
| | - Mei Liu
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Hua-Ping Xie
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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Martino A, Di Serafino M, Zito FP, Maglione F, Bennato R, Orsini L, Iacobelli A, Niola R, Romano L, Lombardi G. Massive bleeding from gastric submucosal arterial collaterals secondary to splenic artery thrombosis: A case report. World J Gastroenterol 2022; 28:5506-5514. [PMID: 36312836 PMCID: PMC9611706 DOI: 10.3748/wjg.v28.i37.5506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/17/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric submucosal arterial collaterals (GSAC) secondary to splenic artery occlusion is an extraordinary rare and potentially life-threatening cause of acute upper gastrointestinal bleeding. Here, we report a case of massive bleeding from GSAC successfully treated by means of a multidisciplinary minimally invasive approach.
CASE SUMMARY A 60-year-old non-cirrhotic gentleman with a history of arterial hypertension was admitted due to hematemesis. Emergent esophagogastroduodenoscopy revealed pulsating and tortuous varicose shaped submucosal vessels in the gastric fundus along with a small erosion overlying one of the vessels. In order to characterize the fundic lesion, pre-operative emergent computed tomography-angiography was performed showing splenic artery thrombosis (SAT) and tortuous arterial structures arising from the left gastric artery and the left gastroepiploic artery in the gastric fundus. GSAC was successfully treated by means of a minimally invasive step-up approach consisting in endoscopic clipping followed by transcatheter arterial embolization (TAE).
CONCLUSION This was a previously unreported case of bleeding GSAC secondary to SAT successfully managed by means of a multidisciplinary minimally invasive approach consisting in endoscopic clipping for the luminal bleeding control followed by elective TAE for the definitive treatment.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Francesco Paolo Zito
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Franco Maglione
- Department of Radiology, Sanatrix Clinic, Napoli 80127, Italy
| | - Raffaele Bennato
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | | | - Raffaella Niola
- Department of Interventional Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
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Patrono D, Franchi E, Guarasci F, Bartoli G, Nada E, Rigo F, Ottobrelli A, Fonio P, Salizzoni M, Romagnoli R. Vascular Remodeling of Visceral Arteries Following Interruption of the Splenic Artery During Liver Transplantation. Liver Transpl 2019; 25:934-945. [PMID: 30882994 DOI: 10.1002/lt.25447] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/01/2019] [Indexed: 02/07/2023]
Abstract
Splenic artery (SA) ligation can be performed during liver transplantation (LT) to avoid portal hyperperfusion, which is involved in the pathogenesis of both small-for-size and SA syndrome. The SA can also be used as an inflow for arterial reconstruction. Exceptionally, SA interruption or agenesis has been associated with positive remodeling of collateral arteries supplying the spleen via the left gastric artery (LGA), short gastric vessels, and the gastroepiploic arcade (GEA), with subsequent severe upper gastrointestinal (GI) bleeding. To determine incidence, magnitude, predictors, and clinical implications of vascular remodeling after SA interruption during LT, we identified 465 patients transplanted in the period 2007-2017 who had the SA ligated or interrupted at LT. Among them, 88 had a computed tomography angiography suitable for evaluation of vascular remodeling after LT. The presence of prominent gastric arterial collaterals and the increase in LGA and GEA diameter were evaluated on 2-dimensional axial images and multiplanar reconstructions. Of the 88 patients, 28 (31.8%), 32 (36.4%), and 22 (25.0%) developed gastric collateralization graded as mild, moderate, or severe. Of the patients for whom comparison with pre-LT imaging was possible (n = 54), 51 (94.4%) presented a median 37% and 55% increase in LGA and GEA diameter, respectively. Severe gastric collateralization was associated with lower body mass index (odds ratio, 0.84; 95% confidence interval [CI], 0.71-0.98; P = 0.03), whereas a GEA caliper measurement increase was positively correlated with Model for End-Stage Liver Disease score (r2 = 0.12; 95% CI, 0.65-4.15; P = 0.008). Out of 465 patients, 2 (0.43%) had severe episodes of arterial upper GI bleeding, possibly exacerbated by vascular remodeling. In conclusion, vascular remodeling after SA interruption during LT is frequent and can aggravate GI bleeding during follow-up.
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Affiliation(s)
- Damiano Patrono
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Eloisa Franchi
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Fabio Guarasci
- Radiology Department, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Germana Bartoli
- Radiology Department, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Elisabetta Nada
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Federica Rigo
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Antonio Ottobrelli
- Gastrohepatology Unit, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Paolo Fonio
- Radiology Department, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Mauro Salizzoni
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
| | - Renato Romagnoli
- Liver Transplant Center, General Surgery 2U, University of Torino, A.O.U. Città Della Salute e Della Scienza, Torino, Italy
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Hanouneh IA, Confer BD, Zein NN, Alkhouri N, Eghtesad B. Recurrent upper gastrointestinal bleeding masquerading as gastric variceal bleeding on endoscopy after liver transplantation. Liver Transpl 2013; 19:926-8. [PMID: 23696498 DOI: 10.1002/lt.23674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 04/28/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Ibrahim A Hanouneh
- Departments of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
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Saddekni S, Abdel-Aal AK, Oser RF, Underwood E, Bag A. Transcatheter embolization of extensive left gastric artery collaterals presenting with massive upper gastrointestinal bleed. Vasc Endovascular Surg 2012; 46:480-3. [PMID: 22669265 DOI: 10.1177/1538574412449908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
We report a case of extensive left gastric artery collaterals that were formed in the region of gastric fundus due to splenic artery occlusion and resulted in massive hematemesis. These collaterals were thought to be portosystemic collaterals related to portal hypertension during upper endoscopy study and single-phase venous computed tomography studies. The collaterals were treated by transcatheter endovascular coil embolization. Our case highlights the importance of recognizing and differentiating left gastric artery collaterals from gastric venous varices as a cause of hematemesis since the treatment approach for each condition is totally different. It also introduces the feasibility of percutaneous left gastric artery embolization as a treatment for this condition, without the need for surgical splenectomy and partial gastrectomy which have a higher mortality and morbidity.
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Affiliation(s)
- Souheil Saddekni
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL 35249, USA
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von Trotha KT, Binnebösel M, Truong S, Behrendt FF, Wasmuth HE, Neumann UP, Jansen M. Severe gastric variceal haemorrhage due to splenic artery thrombosis and consecutive arterial bypass. BMC Surg 2011; 11:14. [PMID: 21711534 PMCID: PMC3142481 DOI: 10.1186/1471-2482-11-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 06/28/2011] [Indexed: 01/16/2023] Open
Abstract
Background Upper gastrointestinal haemorrhage is mainly caused by ulcers. Gastric varicosis due to portal hypertension can also be held responsible for upper gastrointestinal bleeding. Portal hypertension causes the development of a collateral circulation from the portal to the caval venous system resulting in development of oesophageal and gastric fundus varices. Those may also be held responsible for upper gastrointestinal haemorrhage. Case presentation In this study, we describe the case of a 69-year-old male with recurrent severe upper gastrointestinal bleeding caused by arterial submucosal collaterals due to idiopathic splenic artery thrombosis. The diagnosis was secured using endoscopic duplex ultrasound and angiography. The patient was successfully treated with a laparoscopic splenectomy and complete dissection of the short gastric arteries, resulting in the collapse of the submucosal arteries in the gastric wall. Follow-up gastroscopy was performed on the 12th postoperative week and showed no signs of bleeding and a significant reduction in the arterial blood flow within the gastric wall. Subsequent follow-up after 6 months also showed no further gastrointestinal bleeding as well as subjective good quality of life for the patient. Conclusion Submucosal arterial collaterals must be excluded by endosonography via endoscopy in case of recurrent upper gastrointestinal bleeding. Laparoscopic splenectomy provides adequate treatment in preventing any recurrent bleeding, if gastric arterial collaterals are caused by splenic artery thrombosis.
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Cyrany J, Kopacova M, Rejchrt S, Jirkovsky V, Al-Tashi M, Bures J. Gastric arterial bleeding secondary to chronic occlusion of the splenic artery (with video). Gastrointest Endosc 2010; 71:1335; author reply 1336. [PMID: 20598266 DOI: 10.1016/j.gie.2009.09.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 09/27/2009] [Indexed: 01/16/2023]
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Shin EK, Moon W, Park SJ, Park MI, Kim KJ, Lee JS, Kwon JH. Congenital absence of the splenic artery and splenic vein accompanied with a duodenal ulcer and deformity. World J Gastroenterol 2009; 15:1401-3. [PMID: 19294774 PMCID: PMC2658836 DOI: 10.3748/wjg.15.1401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Congenital absence of the splenic artery is a very rare condition. To the best of our knowledge, congenital absence of the splenic artery accompanied with absence of the splenic vein has not been reported. We report a case of the absence of the splenic artery and vein in a 61-year-old woman who presented with postprandial epigastric discomfort. Upper gastrointestinal endoscopy showed a dilated, pulsatile vessel in the fundus and duodenal stenosis. An abdominal computed tomography (CT) scan revealed absence of the splenic vein with a tortuously engorged gastroepiploic vein. Three-dimensional CT demonstrated the tortuously dilated left gastric artery and the left gastroepiploic artery with non-visualization of the splenic artery. After administration of a proton pump inhibitor, abdominal symptoms resolved without any recurrence of symptoms during 6 mo of follow-up.
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Mnatzakanian G, Smaggus A, Wang CS, Common AA, Jeejeebhoy KN. Splenic artery collaterals masquerading as gastric fundal varices on endoscopy: a sticky situation. Gastrointest Endosc 2008; 67:751-5. [PMID: 18206881 DOI: 10.1016/j.gie.2007.09.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 09/22/2007] [Indexed: 02/08/2023]
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Worthley DL, Rayner CK, Devitt PG, Fraser R. Gastric hemorrhage as a late complication of splenic artery aneurysm repair: a dramatic way to vent one's spleen. J Gastroenterol Hepatol 2003; 18:604-5. [PMID: 12702057 DOI: 10.1046/j.1440-1746.2003.03012.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Baron PW, Sindram D, Suhocki P, Webb DD, Clavien PA. Upper gastrointestinal bleeding from gastric submucosal arterial collaterals secondary to splenic artery occlusion: treatment by splenectomy and partial gastric devascularization. Am J Gastroenterol 2000; 95:3003-4. [PMID: 11051401 DOI: 10.1111/j.1572-0241.2000.03228.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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