Mark Shell, DO, Christopher Naumann, MD, Steven Smith, MD, Evan Reinhart, DO; Baylor Scott & White Health, Temple, TX
Introduction: Visceral artery aneurysms (VAAs) are a rare clinical entity, with a reported incidence between 0.01%-0.2%. VAAs are typically found incidentally in asymptomatic patients but can carry a risk of rupture with resultant hemorrhage. While the splenic and hepatic arteries are the most common visceral vessels affected, the gastroduodenal artery (GDA) only accounts for 2% of all VAAs. We present a unique case of bile duct obstruction secondary to extrinsic compression from a gastroduodenal VAA.
Methods: In the identified case, a 46 year old African American female with past medical history significant for obesity, hypertension and tobacco use presented with a chief complaint of acute onset right upper quadrant abdominal pain, nausea, and hematemesis. Initial objective laboratory findings were notable for the following: Hgb 8.6, AST 749, ALT 549, alkaline phosphatase 262, total bilirubin 2.5. A transabdominal ultrasound was performed, revealing a dilated extrahepatic bile duct (10 mm) and a vascular lesion at the junction of duodenum and pancreas concerning for an aneurysm. CT Abdomen/Pelvis confirmed a 3.5 cm enhancing aneurysm involving the gastroduodenal artery with compression of the adjacent bile duct. The patient underwent successful coil embolization of the aneurysm. EUS/ERCP were performed, revealing extrinsic compression of the common bile duct by the gastroduodenal artery aneurysm. Following placement of a biliary stent, the patient’s liver function tests normalized. EUS/ERCP were repeated at 2 and 4 months. At 2 months, the aneurysm had decreased to 1.6 x 1.6 cm with persistent bile duct compression requiring stent exchange. At 4 months, the aneurysm measured 1.2 x 1.0 cm with complete resolution of the biliary obstruction. The biliary stent was removed. Discussion: This case highlights a unique pathogenesis to a familiar presentation of biliary obstruction. While the described patient’s clinical picture warranted urgent evaluation, symptoms of VAAs can range from absent to severe. The early identification of VAAs with imaging modalities is essential for prompt intervention (endovascular or operative) to prevent life threatening complications such as rupture and hemorrhage. A small number of cases have reported VAAs as the causative etiology of biliary obstruction. We highlight the role of endoscopic biliary interventions in the management of this very rare condition.
Gastroduodenal artery aneurysm (orange arrow) seen compressing the common bile duct (green arrow) on coronal view of CT abdomen.
Gastroduodenal artery aneurysm visualized on EUS
ERCP demonstrating biliary stricture secondary to gastroduodenal artery aneurysm
Disclosures: Mark Shell indicated no relevant financial relationships. Christopher Naumann indicated no relevant financial relationships. Steven Smith indicated no relevant financial relationships. Evan Reinhart indicated no relevant financial relationships.