Eur J Vasc Endovasc Surg 14, 413-414 (1997)

CASE REPORT

Left Gastric Artery Aneurysm - A Case Report

S. Khan and 1". Cheatle

Department of General Surgery, Norfolk & Norwich Hospital NHS Trust, Brunswick Road, Norwich, Norfolk NR1 3SR, U.K.

Introduction

Gastric artery aneurysm rupture is a rare but important condition with a high lethal potential. We present a patient who survived this condition and discuss the management.

Cast Report

A 78-year-old man was admitted with a 2 h history of sudden onset epigastric and periumbilical pain followed by collapse. He was taking Warfarin for atrial fibrillation.

On examination he was shocked, with a systolic blood pressure of 52 mmHg and a soft but generally tender abdomen. His haemoglobin was 9.7mg/dl, white cell count was 16.1 x 109/1 and INR was mark- edly deranged at 6.5. ECG, CKMB fraction and amylase were all normal.

After resuscitation with intravenous fluids an emer- gency laparotomy was performed. Two litres of fresh blood were found in the abdominal cavity with a tense haematoma in the lesser sac. This was opened to reveal a ruptured left gastric artery aneurysm.

Intraoperatively the patient sustained an electro- mechanical dissociation arrest due to hypovolaemia, from which he was successfully resuscitated. During surgery he received 15 units of blood and 4 units of fresh frozen plasma. The aneurysm was ligated and resected.

The patient recovered fully and was sent for con- valescence 2 weeks after the operation.

Histology confirmed the diagnosis of a left gastric artery aneurysm about 1.8 cm in diameter. It had a

thick fibrocellular wall (Fig. 1) and contained thrombus undergoing organisation. Its cause was not completely clear, but an atherosclerotic origin seemed most likely.

Discussion

Aneurysms of the gastric arteries are rare, and account for less than 4% of splanchnic artery aneurysms. 1 Men outnumber women three to one and most lesions affect patients in their sixth to seventh decades. 4

They appear to occur as a result of Periarterial inflammation secondary to atherosclerotic destruction of the wall of the artery. Alternatively, it has been proposed that they may be acquired as a result of periarterial inflammation leading to medial de- generationJ They can be classified into: (a) intramural (about 70%), which rupture into the lumen of the stomach and present as acute or chronic upper gastro- intestinal bleeding; or (b) extravisceral (about 30%), which rupture into the peritoneal cavity. 2

Spontaneous intraperitoneal haemorrhage from a ruptured extravisceral gastric artery is an extremely rare occurrence. 2 To date we have found 19 reported cases of extravisceral gastric artery aneurysm in the English language literature.

Patients present with sudden pain, nausea, vomiting and hypovolaemic shock. Rarely, they may describe epigastric discomfort before rupture. 3

Preoperative arteriography may play a role in less acute cases, and some authors recommend intra-op- erative angiography. 5 In most patients, however, treat- ment of gastric artery aneurysm is directed simply at controlling life-threatening haemorrhage. This com- prises vigorous resuscitation and ligation with or with- out excision of the aneurysm. Arterial embolisation has also been found to be successful in some cases. 4

1078-5884/97/110413 + 02 $12.00/0 © 1997 W.B. Saunders Company Ltd.

414 S. Khan and 1". Cheat le

Fig. 1. Photograph of resected specimen, bisected to show thick, fibro-muscular wall.

It has been suggested that asymptomatic lesions found incidentally on ultrasound, computed tomo- graphy (CT) scan duplex or angiography should be electively ligated or embolised to avoid risk of sub- sequent rupture. 5

Our patient presented with classical symptoms. Vig- orous resuscitation and urgent operative intervention considerably improved his chances of survival, as about 70% of patients reported to have these lesions succumb following rupture despite treatment. I Rup- tured splanchnic artery aneurysm should be con- sidered and searched for in patients with a haemoperitoneum in whom no obvious cause can initially be found.

References

1 STANLEY JC, ZELENOCK GB. Splanchnic artery aneurysms. In: Rutherford's Vascular Surgery, Vol. II 4th edn. Philadelphia, W.B. Saunders Co., 1995; 81: 1133.

2 WITTE JT, HASSON JEe t al. Fatal gastric artery dissection and rupture occurring as a paraoesophageal mass: a case report and literature review. Surgery 1990; 107: 590-594.

3 POLLOCK WE, MICHAEL c a . Massive spontaneous haemo- peritoneum due to rupture of visceral branches of the abdominal aorta. Am Surgeon 1979; 45: 621-627.

4 STANLEY JC, WAKEfiELD TW et al. Clinical importance and man- agement of splanchnic artery aneurysms. J Vasc Surg 1986; 5: 837-840.

5 BUSUTILL RW, FREISCHLAG JA. Visceral artery aneurysms. In: Haimovici's Vascular Surgery - - Principles and Techniques, 3rd edn. Connecticut, U.S.A.: Appleton & Lange, 1989; 49: 661.

Accepted 9 May 1997

Eur J Vasc Endovasc Surg Vol 14, November 1997