Active Overt Obscured Gastrointestinal Bleeding Due to Ectasia of the Anterior Inferior Pancreaticoduodenal Artery and Its Endovascular Management in a Treated Case of Superior Mesenteric Artery Stenosis

The term overt obscure gastrointestinal bleeding (OGIB) is defined as patients presenting with either hematochezia or melena, in whom upper and lower endoscopic examinations in addition to a small bowel (SB) series (radiographic/fluoroscopy examination of SB with positive contrast) did not reveal any source of bleeding in the gastrointestinal (GI) tract and may represent a source of bleeding outside the SB.[1] [2] In 85 to 90% of cases with OGIB, a source can be identified,; however, in 5 to 10%, no source of bleeding is found. OGIB from the small intestines is difficult to localize.[1] Small intestinal bleeding is among the less common causes of GI bleeds and accounts for ~5 to 10% of cases. According to the American College of Gastroenterology (ACG) clinical guidelines, in acute overt GI bleeding, conventional angiography should be performed on an emergency basis for hemodynamically unstable patients and computed tomography angiography (CTA) can be performed in hemodynamically stable patients to identify the site of bleeding and to guide further management.[2] The present case report is a description of a rare case of acute overt massive upper GI bleed, 1 month after superior mesenteric artery stenting. Source of bleeding was not found on upper and lower GI endoscopy and CTA. Catheter-based angiography identified anterior inferior pancreaticoduodenal artery (AIPDA) ectasia, which was subsequently embolized successfully.

• References

• 1 Bresci G. Occult and obscure gastrointestinal bleeding: causes and diagnostic approach in 2009. World J Gastrointest Endosc 2009; 1 (01) 3-6
• 2 Gerson LB, Fidler JL, Cave DR, Leighton JA. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol 2015; 110 (09) 1265-1287 quiz 1288
• 3 Pasha SF, Hara AK, Leighton JA. Diagnostic evaluation and management of obscure gastrointestinal bleeding: a changing paradigm. Gastroenterol Hepatol (N Y) 2009; 5 (12) 839-850
• 4 Ramaswamy RS, Choi HW, Mouser HC. et al. Role of interventional radiology in the management of acute gastrointestinal bleeding. World J Radiol 2014; 6 (04) 82-92
• 5 Antoniak R, Grabowska-Derlatka L, Nawrot I, Cieszanowski A, Rowiński O. Aneurysms of peripancreatic arterial arcades coexisting with celiac trunk stenosis or occlusion: single institution experience. BioMed Res Int 2017; 2017: 1645013
• 6 Kallamadi R, Demoya MA, Kalva SP. Inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis/occlusion. Semin Intervent Radiol 2009; 26 (03) 215-223
• 7 Ikeda O, Tamura Y, Nakasone Y, Kawanaka K, Yamashita Y. Coil embolization of pancreaticoduodenal artery aneurysms associated with celiac artery stenosis: report of three cases. Cardiovasc Intervent Radiol 2007; 30 (03) 504-507
• 8 Dave B, Sharma A, Kwolek C, Demoya M, Wicky S, Kalva S. Percutaneous transcatheter arterial embolization of inferior pancreatico-duodenal artery aneurysms associated with celiac artery stenosis or occlusion. Catheter Cardiovasc Interv 2010; 75 (05) 663-672
• 9 Ichinokawa M, Iwai K, Matsumura Y. et al. A case of the anterior superior pancreaticoduodenal artery aneurysm with complete occulusion of the superior mesenteric artery. Jpn J Gastroenterol Surg 2006; 39: 1678-1682
• 10 Kimura C, Adachi H, Yamaguchi A, Ino T. A case of an unruptured inferior pancreaticoduodenal artery aneurysm with celiac artery occulusion and superior mesenteric artery stenosis. Jpn J Vasc Surg 2009; 18: 691-694
• 11 Ikoma A, Nakai M, Sato M. et al. Inferior pancreaticoduodenal artery aneurysm treated with coil packing and stent placement. World J Radiol 2012; 4 (08) 387-390
• 12 Gouny P, Fukui S, Aymard A. et al. Aneurysm of the gastroduodenal artery associated with stenosis of the superior mesenteric artery. Ann Vasc Surg 1994; 8 (03) 281-284
• 13 Moore E, Matthews MR, Minion DJ. et al. Surgical management of peripancreatic arterial aneurysms. J Vasc Surg 2004; 40 (02) 247-253