Endoscopic visualization of an intervention-treated pseudoaneurysm at a duodenal ulcer

Article information

Korean J Intern Med. 2020;35(6):1524-1525

Publication date (electronic) : 2019 December 30

doi : https://doi.org/10.3904/kjim.2019.219

Myung-Won You¹, Chi Hyuk Oh², Se Whan Kwon¹, Seok Ho Dong²

¹Department of Radiology, Kyung Hee University College of Medicine, Seoul, Korea

²Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea

Correspondence to Chi Hyuk Oh, M.D. Tel: +82-2-958-8114 Fax: +82-2-958-8147 E-mail: harrison@hanmail.net

Received 2019 July 3; Revised 2019 September 25; Accepted 2019 November 19.

A 76-year-old man was admitted because of hematemesis, anemia, and hypovolemic shock. He had a history of left hepatectomy, bile duct resection, and chemoradiotherapy for cholangiocarcinoma. Emergent gastroscopy revealed active duodenal ulcer with pulsating pseudoaneurysm in the duodenal bulb (Fig. 1A). Subsequent celiac angiography revealed focal aneurysmal dilatation with a stenotic portion of the proximal right hepatic artery corresponding to the pulsating pseudoaneurysm observed on endoscopy (Fig. 1B). Transarterial embolization (TAE) was performed to treat a pseudoaneurysm. However, massive rebleeding occurred 1 day after the TAE. With the help of emergent angiography, transarterial stent-graft insertion was performed in the pseudoaneurysm where the TAE had previously been performed (Fig. 2A). After the procedure and medication for active duodenal ulcer, follow-up endoscopy was performed. The treated pseudoaneurysm with stent-graft insertion was directly visualized along with the healing duodenal ulcer on endoscopy (Fig. 2B). The patient’s general condition had improved at discharge and the bleeding did not recur.

Figure 1.

(A) Endoscopic image of a pulsating pseudoaneurysm with an active duodenal ulcer (arrows). (B) Celiac angiogram demonstrating a focal aneurysmal dilatation and stenosis in the right hepatic artery (arrow).

Figure 2.

(A) Stent-graft insertion for the treatment of the pseudoaneurysm of the right hepatic artery (arrows). (B) Follow-up endoscopic visualization of the vascular stent (arrows) in the treated pseudoaneurysm through the base of the ulcer.

This case raises two aspects of clinical interest. First, there are no previous reports of direct endoscopic viewing of an inserted vascular stent after a pseudoaneurysm of a duodenal ulcer was treated with transarterial stent-graft insertion. Second, no clear guideline has been issued regarding the optional treatment of intractable gastrointestinal ulcer bleeding. We hope our experience may support the consideration of rescue treatment for similar patients. In our patient, transarterial stent graft was a good treatment option when the endoscopic and TAE treatments failed. Written informed consent was obtained.