review of literature on clinical pancreatology - The Pancreapedia

perforation <strong>of</strong> a pseudoaneurysm into pancreatic pseudocyst in the area <strong>of</strong> the pancreaticbody. The diagnosis <strong>of</strong> hemosuccus pancreaticus, established by endoscopy andpostcontrast CT examination, was confirmed by angiography. It was stopped the acutebleeding from pseudoaneurysm, unusually well supplied by both gastric arteries byembolization <strong>of</strong> both arteries with metallic coils. It was concluded that angiography plays anirreplaceable role in patients with hemosuccus pancreaticus. The case demonstratesbleeding from pseudoaneurysm supplied by both gastric arteries, whose embolizationproduced an immediate hemostasis and improvment the patient's condition [652].Hemosuccus pancreaticus is a rare cause <strong>of</strong> upper chronic and intermittent gastrointestinalhemorrhage which cannot be easily detected by endoscopy. It is usually due to the rupture <strong>of</strong>a visceral aneurysm into the main pancreatic duct; splenic artery pseudoaneurysmassociated with chronic pancreatitis represents the leading cause <strong>of</strong> this condition. Thediagnosis is based on direct visualization <strong>of</strong> the hemorrhage through the main pancreaticduct at angiography. Given its rarity, difficulties in determining the source <strong>of</strong> bleeding canresult in delayed treatment. It was present a rare case <strong>of</strong> true splenic artery aneurysmfistulized in the main pancreatic duct and misdiagnosed as a bleeding pancreatic pseudocyston preoperative examination which included CT and MRCP [653].Pancreatic aneurysmIt was presented a clinical case <strong>of</strong> successful management <strong>of</strong> an aneurysm <strong>of</strong> the inferiorpancreatoduodenal artery, having resulted from occlusion <strong>of</strong> the celiac trunk and acompensatory increase in the blood flow along it from the superior mesenteric artery into thebasin <strong>of</strong> the celiac trunk. In the case report described, the authors used the technique <strong>of</strong>open surgical revascularization <strong>of</strong> the celiac trunk and autovenous prosthetic repair <strong>of</strong> theaneurysmatically altered inferior pancreatoduodenal artery. The surgical decision-makingwas determined by the fact that the commonly accepted endovascular by-pass <strong>of</strong> theaneurysm would have resulted in the development <strong>of</strong> ischaemia in the basin <strong>of</strong> the celiactrunk and unpredictable alterations in the organs supplied thereby [654].Although rare, a pancreatic arteriovenous malformation can have serious consequences. Adiagnosis <strong>of</strong> arteriovenous malformation requires evidence <strong>of</strong> aberrant communicationbetween the arterial and the venous systems. One report described a case where the use <strong>of</strong>multi-detector row CT and specific post-processing methods provided a diagnosis <strong>of</strong>arteriovenous malformation. This minimally invasive diagnostic approach resulted in a clear,precise and comprehensive visual representation <strong>of</strong> the pancreatic arteriovenousmalformation. A 60-year-old man with right hypochondriac pain presented with a mass in thehead <strong>of</strong> the pancreas. The hypochondriac pain resolved spontaneously and physicalexamination revealed no abnormal findings. A multi-detector row CT study was performed.The data obtained in the arterial phase demonstrated a high-contrast mass in the head <strong>of</strong> thepancreas and early enhancement <strong>of</strong> the portal vein. A maximum intensity projection methodclarified the aberrant vascular communication. Changes in Hounsfield numbers wereobserved using a multi-planar reformation method. A volume-rendering method was used tocreate a 3D model which demonstrated the spatial relationship between the aberrantvascular communication and the surrounding tissue. An annual follow-up study using thistechnique showed no significant alteration [655].