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Superior pancreaticoduodenal artery pseudoaneurysm mimicking a cystic neoplasm with worrisome features

Open AccessPublished:December 12, 2016DOI:https://doi.org/10.1016/j.vgie.2016.11.002
      A 61-year-old woman presented with poor appetite, unintentional weight loss (>30 pounds in 1 year), and intermittent diarrhea. She had undergone a CT in 2012 at another hospital; the scan showed no significant abnormalities. Further investigation with magnetic resonance imaging (MRI) revealed a 1.4-cm cystic lesion in the body of the pancreas, with wall thickness and enhancing nodule, suggestive of a cystic neoplasm with worrisome features (Figs. 1A and B ). The patient was then referred for EUS with possible EUS-FNA. EUS showed the pancreatic lesion with the same worrisome features described previously during the MRI (Fig. 1C). However, examination with Doppler US revealed an intense vascular flow in the lesion. The intensely pulsating mass with connection with a surrounding artery raised concern about a diagnosis of pseudoaneurysm with partial thrombosis mimicking the solid components (Fig. 1D). A CT angiogram confirmed the pancreatic pseudoaneurysm arising from the superior pancreaticoduodenal artery (Fig. 1E). The patient was then successfully treated with angiographic embolization (Fig. 1F). The patient had experienced no pain or bleeding episodes at the 3-month follow-up visit. An interval CT scan of the percutaneous embolization showed complete exclusion of the aneurysm with no evidence of recanalization. The underlying cause of her diarrhea was presumed to be irritable bowel syndrome, with workup results that were unremarkable for infectious, inflammatory, or secretory origins. Our patient described a year-long history of significant personal stressors in her life before her presentation. This is an unusual case of a pancreatic pseudoaneurysm mimicking a cystic neoplasm in a patient with no medical history of pancreatitis (Video 1, available online at www.VideoGIE.org). The presentation may range from an incidental finding up to hemodynamic collapse from severe bleeding. EUS is an important tool in this diagnosis. Moreover, examination of a lesion referred for EUS-FNA with Doppler US is always recommended to avoid puncture of vascular structures. Although EUS-guided treatment is not the criterion standard for pseudoaneurysms, some publications have reported successful EUS-guided embolization with thrombin.
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      Figure 1A, Magnetic resonance image showing a cystic lesion in the body of the pancreas with wall thickness. B, Enhancing nodule as shown by MRI, suggestive of a cystic neoplasm with worrisome features. C, EUS image showing the pancreatic lesion with worrisome features described previously by the MRI. D, Doppler US image revealing an intense vascular flow and connection of the lesion with a surrounding artery. E, CT angiographic image confirming the superior pancreaticoduodenal artery pseudoaneurysm. F, Fluoroscopic image after treatment with angiographic embolization. MRI, magnetic resonance imaging.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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