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Gastroduodenal and Pancreaticoduodenal Artery Aneurysms
Gastroduodenal artery aneurysms account for 1.5% and pancreatic and pancreaticoduodenal artery aneurysms account for 2% of all splanchnic artery aneurysms. These aneurysms are usually categorized as being either pseudoaneurysms or true aneurysms. It is important to acknowledge their differences regarding pathogenesis, clinical manifestations including risk to life, and the various means of their management. Arteriosclerosis is often present in both aneurysmal types and is considered a secondary process.
Pseudoaneurysms
Approximately 50% of gastroduodenal and 30% of pancreaticoduodenal artery aneurysms are related to pancreatitis ( Figures 1 and 2 ). Pseudoaneurysms of these arteries are most often a consequence of pancreatitis. Mechanisms of aneurysmal formation in this setting include acute or subacute vascular disruption by activated pancreatic enzymes and later chronic pseudocyst erosion into an adjacent artery. Traumatic aneurysms, especially as a result of iatrogenic injury associated with hepatobiliary and pancreatic operations, are uncommon, but when they do occur they most often involve the gastroduodenal artery. Septic emboli are a rare cause of pseudoaneurysms affecting these peripancreatic arteries.
Clinical Manifestations
Most patients with pseudoaneurysms experience abdominal pain. In the majority of patients this pain is a reflection of the underlying pancreatic inflammatory disease. Unremitting epigastric abdominal pain unrelated to eating or position, often accompanied by back discomfort, has been commonly associated with these aneurysms. The pain may be excruciating in the case of expanding aneurysms.
Rupture is the most serious complication of these pseudoaneurysms. Bleeding may be somewhat covert, with chronic loss of blood into the gastrointestinal tract, manifest by melanotic stools and an anemia, or it may be overtly catastrophic, with exsanguinating hemorrhage and vascular collapse. Retroperitoneal or peritoneal cavity rupture occurs less often than into the gastrointestinal tract. When the latter occurs the sites of rupture include the duodenum, stomach, common bile duct, and colon. Surprisingly, these inflammatory aneurysms carrying a risk of rupture less than 10%. In general, the overall mortality approaches 20% following rupture of pseudoaneurysms affecting both the gastroduodenal and pancreaticoduodenal arteries. An exception exists with rupture into the stomach, which carries a 75% risk of death, likely caused by delays in diagnosis and unchecked bleeding from a major arterial erosion.
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