Virginia Tech Carilion School of Medicine Clarksville, MD, United States
Agazi Gebreselassie, MD, MSc1, Manoj Kumar, MD2 1Virginia Tech Carilion School of Medicine, Clarksville, MD; 2Virginia Tech Carilion School of Medicine, Roanoke, VA
Introduction: The majority of pancreatic lesions that are found in cross sectional studies are cystic lesions. Incidental finding of solid pancreatic lesions is uncommon. Adenocarcinomas and neuroendocrine tumors constitute majority of the incidentally found solid tumors. Here we describe a rare cause of pancreatic lesion which was incidentally identified on cross sectional imaging and how endoscopic ultrasound was used to settle the diagnosis.
Case Description/Methods: A 70-year-old male with history of hypertension and obstructive sleep apnea had a chest CT angiography done for evaluation of chest pain. An incidental rounded 9.3 mm structure was seen between the region of the pancreatic head and second duodenal segment. MRI was done to further characterize the lesion. MRI showed a pancreatic head 12 mm rounded nodule just anterior and leftward of the main pancreatic duct. Neuroendocrine tumor was favored on MRI. Patient was referred for EUS exam.
Anechoic circular lesion measuring 9 mm was seen in the head of the pancreas on endoscopic ultrasound when visualized from second part of the duodenum. The lesion had sluggish flow on doppler. On close examination the lesion was attached seen to have two linear extensions. Doppler exam on the two extensions was consistent with arterial waves. This is consistent with aneurysm.
The patient then underwent CT angiography and with successful coil embolization of an aneurysm arising from a branch of the gastroduodenal artery. Patient continues to do well three month after procedure.
Discussion: Gastroduodenal aneurisms are rare representing about 1 % of all visceral aneurisms. Undiagnosed and untreated gastroduodenal aneurisms can be fatal. Pseudoaneurisms as the result of atherosclerosis and pancreatitis are more common than true aneurisms. Our patient most likely has a pseudoaneurism as a result of atherosclerosis taking in to account his risk factors. He never had history of pancreatitis and does not drink alcohol either. The gold standard for diagnosis of aneurism is angiography. However patients may be referred for endoscopic ultrasound after a pancreatic lesion is seen on other modalities of imaging such as ultrasound, non-contrast CT or MRI. The diagnosis can also easily be missed on endoscopic ultrasound as the eyes are mostly trained to identify non vascular lesion (masses and cysts). It needs high index of suspicion and careful evaluation of the vascular structures under doppler to diagnose visceral aneurisms.
Figure: EUS with doppler study
Agazi Gebreselassie indicated no relevant financial relationships.
Manoj Kumar indicated no relevant financial relationships.
Agazi Gebreselassie, MD, MSc1, Manoj Kumar, MD2. P1127 - The Role of Endoscopic Ultrasound in the Diagnosis of a Rare Intrapancreatic Aneurysm: Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.