The differential for a patient presenting with melena is large. Splenic artery pseudoaneurysm is uncommon, and it is a rare cause of gastric mass and upper gastrointestinal bleeding. We present a case of gastrointestinal bleed resulting from a large splenic artery pseudoaneurysm.
A 67-year-old male presented to the hospital with two day history of loose stools and melena. This was associated with decrease in appetite and nine pounds weight loss over the last several weeks. Patient did not have any nausea, vomiting, or abdominal pain. On presentation, patient's vital signs were within normal limits. Physical exam was unremarkable. Labs showed a white blood cell count of 10.9 × 109/L, hemoglobin of 9.2 g/dl (baseline was 12.8 g/dl), and platelets of 175 × 109/L. INR was 1.2. CT scan of the abdomen and pelvis with contrast showed a large 5.4 × 4.8 × 3.6 cm mass-like structure adjacent to the lesser curvature of the stomach, demonstrating either a large saccular aneurysm of the splenic artery or an exophytic gastrointestinal stromal tumor (GIST) which had eroded the splenic artery.
Upon admission, an angiogram was performed. It showed a large splenic artery pseudoaneurysm. The adjacent splenic artery was coil embolized. An EGD was performed two days later, and it showed a large 4–5 cm, submucosal, partially circumferential mass with a 5 mm area of ulceration. Lesion was suspicious for GIST. Biopsies were taken. An EUS was performed afterwards, and it showed a large bulging area noted at the junction between the fundus and the body of the stomach on the lesser curvature. No submucosal GIST was identified. Patient had an uneventful hospital course thereafter and required no further intervention. Pathology from the biopsy of the mucosa during EGD showed normal gastric mucosa.
Pseudoaneurysm of the splenic artery is rare with a high risk of rupture. It is uncommon for the pseudoaneurysm to externally compress the stomach resulting in bleeding. Splenic pseudoaneurysm can result from a pancreatic enzyme leak causing vascular erosion, or from a pancreatic pseudocyst causing direct compression. Treatment includes new endovascular techniques such as embolization and endovascular stenting. As splenic artery pseudoaneurysm is a very rare cause of gastrointestinal bleeding, a high degree of suspicion is needed to reach the diagnosis.