Aneurysms of the hepatic artery are rare. The presenting features include abdominal pain, which may be associated with a mass. More acutely, patients present with signs of hypovolaemia secondary to rupture. The patient reported here presented with gastrointestinal haemorrhage of unknown aetiology. A computed tomography scan showed an aneurysm of a visceral artery. Subsequent angiography confirmed the presence of a leak in the hepatic artery. The patient refused surgical intervention and improved with supportive treatment only.
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Hepatic artery aneurysms are rare lesions presenting as rupture, a mass, or with pain. We report an unusual case of a patient with hepatic artery aneurysm who presented with gastrointestinal haemorrhage.
An 85 year old woman presented with acute gastrointestinal haemorrhage. She had a two month history of abdominal pain and a five day history of rectal bleeding, weakness, and lethargy. There was no history of prior use of non-steroidal anti-inflammatory drugs. On arrival the patient was haemodynamically stable, but she had mild epigastric tenderness and fresh blood was seen on rectal examination.
Her initial blood and radiological investigations were normal. Upper gastrointestinal endoscopy and flexible sigmoidoscopy did not reveal any significant abnormality apart from transported blood in the colon. A computed tomography (CT) scan showed a 6 cm aneurysm (fig 1) in relation to one of the visceral arteries, which had two concentric rings of calcification. The artery of origin could not be identified and an angiogram was done. This confirmed the presence of an aneurysm in the hepatic artery. The pancreas was also highly calcified.
She was treated conservatively and the bleeding stopped spontaneously. The option of surgery was discussed, but this was declined by the patient and her relatives.
Hepatic artery aneurysms are rare lesions (20% of all visceral aneurysms1) and difficult to diagnose clinically. They can present as a dull ache, lump, obstructive jaundice, or rarely as bleeding into the gastrointestinal tract. The common causes include surrounding inflammation, trauma, or atherosclerosis.2 Selective angiography of the coeliac axis and superior mesenteric artery are essential, not only to confirm the diagnosis, but also to supply important information about related vascular anatomy, which is invaluable while planning the operative strategy. Other investigative tools include ultrasound, which may show a turbulent arterial waveform3 with high peak velocity, and three dimensional CT angiography.4
Management options range from reconstruction using prosthetic grafts to excision or embolisation.5 Surgery is the treatment of choice for extrahepatic aneurysms, whereas radiological embolisation is more appropriate for intrahepatic aneurysms.6 Some experts have suggested reserving embolisation for aneurysms which are difficult to operate upon due to poor accessibility.7
Competing interests: none declared
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