Jalpa Patel, MD1, Nicholas Battista, MD1, Dina Fakhouri, DO2, Akash Patel3, Matthew Osher, MD4, Eric Rinker, MD4, Michael Piper, MD5, Bradley Warren, DO5; 1Providence Hospital, Southfield, MI; 2Ascension Macomb-Oakland, Birmingham, MI; 3Arizona College of Osteopathic Medicine, Anaheim, CA; 4Ascension Health Providence Hospital, Novi, MI; 5Digestive Health Associates, PC, Farmington Hills, MI
Introduction: The two leading causes of acute pancreatitis are gallstones and alcohol abuse. Patients with advanced age presenting with their first episode of pancreatitis, malignancy appears higher on the differential. Here we discuss a case of localized inflammation thought to be a pancreatic mass uncovering a common hepatic artery aneurysm.
Methods: 59 year old Caucasian male with a past medical history of hypothyroidism and hyperlipidemia presented with acute onset nonradiating left upper quadrant pain. He denied any other symptoms. Denied excess alcohol use orbinge drinking. Physical exam revealed a soft nondistended abdomen with minimal tenderness in the epigastrium and right upper quadrant, no rebound, guarding or signs of peritonitis. Laboratory work upon admission showed lipase 2,015 units/L, amylase 888 units/L. Liver function, IgG and triglyceride levels were within normal limits. RUQ US showed no cholelithiasis but an abnormal echogenicity with flow in the head of the pancreas. CT abdomen and pelvis with contrast revealed a mass/hypoattenuating collection at the head of the pancreas measuring 3.3x 3.4x 6.7 cm with minimal fat stranding and dilation of the distal pancreatic ductal. CEA and CA 19-9 were obtained both of which were within normal limits. MRCP showed mixed signal structure centered at the pancreatic neck and common hepatic artery at celiac bifurcation. CT angiography abdomen and pelvis showed a well defined structure inseparable from and with mass effect on the pancreas relating to an aneurysm. Interventional radiology successfully embolized the common hepatic artery aneurysm while preserving hepatic arterial flow through gastroduodenal artery collaterals. CT pancreatic protocol completed 7 days after discharge to rule out underlying pancreatic malignancy confirmed successful treatment of the common hepatic artery aneurysm, with patent vasculature and no pancreatic mass noted. Discussion: Hepatic artery aneurysms account for about 20% of all visceral aneurysms, often presenting once they have ruptured, and therefore associated with high mortality. A small percentage of aneurysms can present with nonspecific abdominal pain, obstructive jaundice or rarely as a GI hemorrhage. Hepatic artery aneurysm causing pancreatitis is rare. Treatment of hepatic artery aneurysm includes reconstruction with surgical prosthetic grafts or embolization. Prior to either treatment angiography is critical to determine patent vasculature and flow pre and post procedure.
Figure 1. Image A is a contrast enhanced axial CT, Image B is a color flow image of the abdomen showing the mass in the region of the pancreatic head (arrow), notice the prominent color flow on ultrasound almost having the appearance of a ‘yin-yang’ suggesting an aneurysm. Images C and D are T2 coronal and axial Fiesta MRI sequences of the abdomen obtained as part of an MRCP study which show a hypointense mass (arrows) causing obstruction of the dilated downstream pancreatic duct (arrow heads).
Figure 2. Images A and B are Coronal MIP CTA and 3-D Rendered image of the abdomen demonstrate the hepatic artery aneurysm which measured up to 3.9 cm in maximum diameter.
Figure 3. Image A is a digital subtraction angiogram of the common hepatic artery demonstrated filling of the common hepatic artery aneurysm, as well as the proper hepatic artery and it’s branches and the gastroduodenal artery. Image B is a digital subtraction angiogram of the superior mesenteric artery after embolization of the aneurysm which shows preserved flow to the proper hepatic artery via the gastroduodenal artery collateral pathway.
Disclosures: Jalpa Patel indicated no relevant financial relationships. Nicholas Battista indicated no relevant financial relationships. Dina Fakhouri indicated no relevant financial relationships. Akash Patel indicated no relevant financial relationships. Matthew Osher indicated no relevant financial relationships. Eric Rinker indicated no relevant financial relationships. Michael Piper indicated no relevant financial relationships. Bradley Warren indicated no relevant financial relationships.