Pancreatic arteriovenous malformation observed to bleed from the bile duct and a duodenal ulcer: report of a case

Successful Surgical Resection of Pancreatic Arteriovenous Malformation Complicated by Acute Pancreatitis

A 73-year-old man presented with left hypochondral pain. Dynamic computed tomography (CT) revealed abnormal vessels surrounding the pancreas, leading to a suspected diagnosis of pancreatic arteriovenous malformation (PAVM). At the time of the initial examination, dynamic CT revealed mild acute pancreatitis, and PAVM was diagnosed based on the findings of dynamic CT. Although repeated abdominal pain was observed after the improvement of pancreatitis, distal pancreatectomy was performed. At >1 year after surgery, no recurrence of PAVM was observed. Surgical resection should be considered in patients with symptomatic PAVM.

Pancreatic arteriovenous malformation treated with transcatheter arterial embolization: Two case reports and review of literature

BACKGROUND

Various treatment methods are available for the treatment of pancreatic arteriovenous malformation (P-AVM); however, there are no established treatment options for asymptomatic P-AVM.

CASE SUMMARY

A 47-year-old and a 50-year-old male patients sought treatment for P-AVM in the pancreas, which was incidentally detected during routine abdominal computed tomography and magnetic resonance imaging conducted as part of a health check-up. They underwent transcatheter arterial embolization (TAE), and over the course of a 9-year follow-up period, the AVM did not worsen and was asymptomatic.

CONCLUSION

TAE can be considered as an alternative treatment option for P-AVM in selective cases where patients are asymptomatic or have a high surgical risk.

Rare cause of obstructive haemobilia with recurrent biliopancreatic complications: a paradigmatic case

Haemobilia is an unusual but significant cause of upper gastrointestinal bleeding. Two-thirds of haemobilia cases are secondary to invasive hepato-biliopancreatic procedures. Biliary angiodysplasia is exceptionally unusual, with only three cases reported. Herein, we report the case of an autonomous 80-year-old woman with a history of cholecystectomy 5 years ago and cardiovascular disease-hypertension, heart failure, acute myocardial infarction, stroke and non-valvular atrial fibrillation, anticoagulated with apixaban 2.5 mg two times per day. Since July 2019, she had four episodes of acute cholangitis of mild-to-moderate severity, having undergone broad spectrum antibiotics treatment and endoscopic retrograde cholangiopancreatography (ERCP), with sphincterotomy and bile sludge extraction. After 3 months, the patient presented with a new episode of acute cholangitis, this time with haemobilia (Quincke's triad). An abdominal CT angiography showed no evidence of active bleeding, with plastic biliary prosthesis left by ERCP. The patient continued presenting new episodes of acute cholangitis with haemobilia, some of them with associated pancreatitis. A cholangioscopy with Spyglass DS II was performed, showing an angiodysplasia occupying half of the luminal circumference of the middle choledoccus, without active haemorrhage. After a multidisciplinary meeting and given the high haemorrhagic/thrombotic risk (CHA2DS2-VASc 8), closure of the left atrial appendage was considered. However, relapse of the condition after beginning the antiaggregation protocol for cardiovascular intervention made it unfeasible. Another cholangioscopy with an ultra-thin endoscope for argon-plasma coagulation was attempted, without success. The abdominal CT angiography was repeated, this time with identification of dilated ramifications of the gastroduodenal and inferior pancreatic arteries. After embolisation of these aberrant vessels with microcoils, the patient went well, with no recurrence of bleeding or biliopancreatic complications. We present a case of obstructive haemobilia with multiple biliopancreatic complications, secondary to an extremely rare cause-choledochal angiodysplasia. Cholangioscopy had a decisive role in the diagnosis and therapeutic guidance. The diagnostic/therapeutic challenge associated with haemobilia stands out, with the need for a personalised and multidisciplinary approach.

Management of pancreatic arteriovenous malformation: Case report and literature review

INTRODUCTION

Pancreatic arteriovenous malformation (P-AVM) is a rare vascular malformation. Fewer than 200 cases have been reported. The clinical manifestations lack specificity. Common symptoms include abdominal pain, gastrointestinal hemorrhage, and jaundice, which is easily confused with other disorders.

PATIENT CONCERNS

A 42-year-old man received TAE due to abdominal pain caused by P-AVM in a local hospital, melena and abdominal pain occurred in a short time after TAE.

DIAGNOSIS

The patient was diagnosed as P-AVM which was confirmed by computed tomography and digital subtraction angiography.

INTERVENTIONS

A pylorus-preserving pancreatoduodenectomy was successfully performed after diagnosis was made.

OUTCOMES

The patient recovered with no complications two weeks after surgery, and no sign of recurrence was found during the 4-mo follow-up period.

CONCLUSION

In our experience, TAE may have limitations in the treatment of P-AVM and surgical resection should be considered as the treatment of choice.

Arteriovenous malformation in the pancreatic head initially mimicking a hypervascular mass treated with duodenum-preserving pancreatic head resection: a case report

Background

The mainstay treatment for arteriovenous malformation in the pancreatic head (Ph-AVM) is standard pancreatectomy, especially pancreaticoduodenectomy (PD), or interventional endovascular treatment. We report the first case of Ph-AVM treated with duodenum-preserving pancreatic head resection (DPPHR) performed to preserve the periampullary organs.

Case presentation

A 59-year-old man presenting with back pain underwent contrast-enhanced computed tomography followed by angiography of the anterior superior pancreaticoduodenal artery. He was diagnosed with Ph-AVM and indicated for DPPHR with preservation of the periampullary organs; Ph-AVM’s benign nature seldom requires lymph node dissection. During the operation, the right colon was mobilized and the omental bursa was released to expose the periampullary structures. The pancreas was transected just above the superior mesenteric vein. The inferior pancreaticoduodenal artery and papillary arteries branching from the posterior superior pancreaticoduodenal artery were carefully preserved to maintain the blood flow to the lower bile duct and papilla of Vater. The remnant pancreas was reconstructed with pancreaticogastrostomy using the modified Blumgart method. Pathological examination of the resected specimen revealed an irregular course of the arteries and veins concomitant with marked dilation throughout the pancreatic head. The patient was pathologically diagnosed with Ph-AVM. He developed hematemesis caused by a rupture of the pseudoaneurysm on postoperative day 20 and underwent coil embolization. A bilio-enteric fistula and stenosis of the common bile duct were found and treated by placement of an endoscopic biliary stent. At the 8-month follow-up, the Ph-AVM had not recurred.

Conclusions

Compared to PD, DPPHR confers the clinical benefit of preserving the periampullary organs, although further studies are needed to confirm this. Therefore, the choice of this procedure should be based on the surgical morbidities and long-term outcome of the patient.

Bleeding from pancreatic arteriovenous malformation with duodenal ulcer penetration. Case report and literature review

Dilated vessels at the ulcer floor of the second part of the duodenum can be signs of pancreatic arteriovenous malformation; contrast-enhanced computed tomography should be performed, and surgical treatment should be considered.

Hemobilia caused by pancreatic arteriovenous malformation: A case report and literature review

RATIONALE

Hemobilia caused by arteriovenous malformation is extremely rare but could be lethal. To date, most reports have been single-case reports, and no literature reviews are available.

PATIENT CONCERNS

A 47-year-old man presented to the emergency department with abdominal pain and fever. He complained of abdominal pain and weight loss for the past 2 months.

DIAGNOSES

Contrast-enhanced computed tomography and magnetic resonance imaging showed a heterogenous lesion located in pancreatic head and tumor was suspected.

INTERVENTIONS

Endoscopic retrograde cholangiopancreatography was performed and bleeding from papilla of Vater could be viewed. Nasobiliary drainage was placed to alleviate the pain and jaundice. Emergency laparotomy was performed due to the recurrence of severe pain and bleeding, and pancreatoduodenectomy was then performed. Macroscopic examination showed the ulceration connected with collected vessels which were located in pancreatic head and microscopic examination confirmed the presence of arteriovenous malformation.

OUTCOMES

The patient recovered uneventfully and was discharged 10 days after the surgery. He is asymptomatic on 4-month follow up.

LESSONS

Arteriovenous malformation is a rare cause of hemobilia, but it could lead to life threatening bleeding. Transarterial embolization could be effective to control the bleeding temporarily, however repeated hemorrhage may occur. Surgical resection may be a better option.

A case of pancreatic AV malformation in an elderly man

A 60-year-old man presented with recurrent abdominal pain and weight loss for 6 months. Abdominal imaging showed a large vascular lesion in the head and neck of pancreas suggestive of arteriovenous malformation (AV malformation). Endoscopic ultrasound was done which showed features of AV malformation with no evidence of pancreatic malignancy. Surgery was planned for definitive treatment of malformation. Digital subtraction angiography with angioembolization was done prior to surgery to reduce vascularity of the lesion. He recovered after a pylorus preserving pancreaticoduodenectomy. Histopathology of the resected specimen confirmed the pancreatic AV malformation. There has been no recurrence at 2 years of follow-up.

Arteriovenous malformation of the pancreas: a case report

Arteriovenous malformation (AVM) of the pancreas is uncommon in the gastrointestinal tract. We present a case of AVM of the pancreatic head in a 59-year-old male. He was admitted to a hospital with hematemesis and tarry stool and referred to our hospital in March 2014 on the diagnosis of pancreatic artery pseudoaneurysm. A computed tomography scan showed the presence of irregular dilated and/or stenotic vessels with meandering in the pancreatic head. Magnetic resonance imaging showed strong enhancement of the conglomeration in the pancreatic head. Selective angiography showed the proliferation of a vascular network in the pancreatic head and an early visualization of the portal vein at the arterial phase. The patient qualified for surgery with a preoperative diagnosis of AVM of the pancreatic head. We performed pylorus-preserving pancreaticoduodenectomy. The histological results confirmed the presence of irregular dilated tortuous arteries and veins in the pancreatic head. Surgical treatment may represent definitive management of symptomatic AVM.

Acquired Pancreatic Arteriovenous Malformation

Pancreatic arteriovenous malformation is a rare vascular anomaly which may cause abdominal pain, acute pancreatitis, gastrointestinal bleeding and portal hypertension. Pancreatic arteriovenous malformation is mostly congenital; however secondary pancreatic arteriovenous malformation due to pancreatitis has been suggested by some authors. We encountered a case which can confirm this presumption. Several imaging modalities are useful for the diagnosis of pancreatic arteriovenous malformation, especially dynamic contrast-enhanced studies. Angiography is the most important diagnostic tool because of the dynamic features of this vascular lesion. Treatment is advised and consists of surgical resection and/or transarterial embolization.

Pancreatic arteriovenous malformation

BACKGROUND

Pancreatic arteriovenous malformation is very rare, but may cause significant clinical symptoms such as catastrophic bleeding. Herein, we discuss the clinical presentation and management of patients pancreatic arteriovenous malformations.

METHODS

The data pool for the analysis was collected from pancreatic arteriovenous malformation cases encountered by our institution and sporadic case reports in the English literature.

RESULTS

A total of 89 cases of pancreatic arteriovenous malformation were collected for this study, including 59 cases of arteriovenous malformation in the pancreatic head (62.3 %) and 30 in the pancreatic body-tail (33.7 %). The most commonly associated complications for overall cases of pancreatic arteriovenous malformation were bleeding (50.6 %), pancreatitis (16.9 %), portal hypertension (6.7 %), and pseudocyst (3.4 %). The most common presenting symptom of pancreatic arteriovenous malformation was gastrointestinal bleeding (47.2 %), followed by epigastric pain (46.1 %). Surgery (43.8 %) was the most common treatment for pancreatic arteriovenous malformation cases, followed by transarterial embolization (11.2 %), a combination of surgery and transarterial embolization (10.1 %), and radiotherapy (2.2 %). No intervention was done for 29.2 % of the cases of pancreatic arteriovenous malformation.

CONCLUSIONS

Pancreatic arteriovenous malformation occurs most commonly in the pancreatic head; gastrointestinal bleeding is the main symptom. Surgical resection or transarterial embolization appears to be indicated in patients with symptomatic pancreatic arteriovenous malformation.

Arteriovenous malformation of the pancreas: A case report and review of literature

Extrahepatic arteriovenous malformations (AVMs) of the gastrointestinal (GI) tract are rare and mostly asymptomatic congenital anomalies. The present case describes a 45-year-old woman with an AVM in the head of the pancreas, which caused massive GI bleeding that recurred after embolization, and which was subsequently treated with a pylorus-preserving Whipple pancreaticoduodenectomy. The authors then review the available literature pertaining to AVMs of the GI tract, the diagnostic modalities that have been used to identify them and the treatment approaches that have been described to date, which range from coil embolization of the feeding artery to radical resection of the affected organ. It is important to remember that these lesions shunt blood between the high-pressure arterial system and the low-pressure portal system, which leads to the much-dreaded consequence of portal hypertension.

Surgical outcomes of pancreatic arteriovenous malformation in a single center and review of literature

OBJECTIVE

Pancreatic arteriovenous malformation (P-AVM) is an extremely rare condition that can be accompanied by fatal complications. We have attempted to identify the possible management guidelines based on our and others' clinical experience.

METHODS

We retrospectively analyzed our findings including clinical characteristics, imaging modalities, and treatment in 12 patients. Sporadic reports of 69 patients with P-AVM were surveyed for representative characteristics and treatment strategy.

RESULTS

The mean age at diagnosis was 49.8 years (range, 44-64 years), and all 12 were male. The mean body mass index was 21.5 kg/m (range, 18.3-24.3 kg/m) and 6 (50%) were heavy smokers (mean, 30.9 pack-years; range, 7.5-120 pack-years). The most common clinical symptom is gastrointestinal bleeding, followed by abdominal pain. All patients were diagnosed with abdominal disease using computed tomography. Of the 12 patients, 11 underwent pancreatic resection and 1 patient was managed conservatively. No patient experienced any major postoperative complications during the median follow-up of 37 months.

CONCLUSIONS

In patients with symptomatic P-AVM, surgical resection of the affected pancreas showed a successful result. When a patient is at a high risk for surgical treatment, transjugular intrahepatic portosystemic shunt, transarterial embolization, and radiation therapy might be other treatment options.

A case of recurrent infection caused by a pancreaticoduodenal fistula associated with a pancreatic arteriovenous malformation

Although arteriovenous malformations (AVM) occur frequently in digestive organs, pancreatic AVM is rare. The clinical symptoms of pancreatic AVM are variable and include gastrointestinal bleeding, abdominal pain, jaundice, portal hypertension, pancreatitis, and duodenal ulcer. However, choledochoduodenal or pancreaticoduodenal fistulas complicated with ascending infection and pancreatitis is extremely rare. Herein, we report a case of pancreaticoduodenal fistula associated with a pancreatic AVM that induced recurrent anemia and ascending infection.

Arteriovenous malformation of the pancreatic head--difficulties in diagnosis and treatment

A patient with pancreatic arteriovenous malformation who presented diagnostic and therapeutic difficulties is presented. The initial tests appeared to suggest inflammatory bowel disease, but the diagnosis was clinched by the finding of blood issuing from the ampulla of Vater. Repeated angiographic embolization did not obliterate the vascular malformation, and the symptoms eventually resolved after Whipple's pancreaticoduodenectomy.

A Case of Recurrent Acute Pancreatitis due to Pancreatic Arteriovenous Malformation

Pancreatic arteriovenous malformation (AVM) is an extremely rare condition with various clinical manifestations. We report herein a case of recurrent acute pancreatitis due to pancreatic AVM in a 49-year-old man. This patient presented with epigastric pain that had developed after consuming alcohol 2 days prior to admission. Serum amylase and lipase levels were elevated and computed tomography revealed focal low-attenuation lesions with peripancreatic infiltrations in the pancreatic tail and multiple collateral vessels around the low-attenuation lesions. He was diagnosed with acute pancreatitis and pancreatic AVM. Although he had stopped drinking after the first attack of acute pancreatitis, his pancreatitis recurred twice within 3 months. He underwent a distal pancreatectomy after the third attack of acute pancreatitis. He was free of symptoms for 2 years after the pancreatectomy.

Small arteriovenous malformation of the common bile duct causing hemobilia in a patient with hereditary hemorrhagic telangiectasia

We report a 54-year-old male patient with arteriovenous malformation located at the common bile duct and hereditary hemorrhagic telangiectasia. The patient was treated as gallstone pancreatitis at first. Three days after endoscopic nasobiliary drainage (ENBD) for biliary drainage to subside gallstone pancreatitis, hemobilia was drained from the ENBD tube and the serum hemoglobin level gradually decreased. Cholangioscopy and angiography revealed that hemobilia was due to a small arteriovenous malformation located at the common bile duct. Subsequently, the patient was successfully treated by endovascular intervention.

Arteriovenous malformation of the pancreas: report of a case

Arteriovenous malformation (AVM) of the pancreas (AVMP) is uncommon and generally asymptomatic; therefore, few cases have so far been reported. The symptoms of AVMP include gastrointestinal bleeding, pain, and portal hypertension. Definitive diagnosis is confirmed by angiographic study, and surgery is the only effective treatment. We report a case of AVMP confirmed by computed tomography, magnetic resonance imaging, and angiographic study of the abdomen, in a patient who presented to us with epigastric pain. He underwent a pancreaticoduodenectomy, following which his symptoms resolved.

[Angiectatic pseudocyst of the pancreatic head]

BACKGROUND

Arteriovenous malformations of the pancreas are very rare, most frequently congenital ones, but tending to increase frequency, predominantly due to the introduction and use of new diagnostic modalities. They usually present with gastrointestinal bleeding and abdominal pain.

CASE REPORT

The autors presented a 52-year-old woman in whom, during the investigation for the abdominal pain and gastrointestinal bleeding, an ultrasonography showed a hypoechogenic lesion within the head of the pancreas 3 cm in diameter. Endoscopic ultrasound showed an irregular hypoechogenic lesion. Computed tomography showed a low density area within the lesion (< 10HU). At endoscopic retrograde cholangiopancreatography, a cystic lesion within the head of the pancreas was filled with contrast from the normal pancreatic duct. Angiography showed an arteriovenous malformation within the head of the pancreas. The patient underwent pylorus preserving cephalic duodenopancreatectomy. The diagnosis of arteriovenous malformation, probably of congenital origin, was confirmed on histology.

CONCLUSION

Arteriovenous malformations should be considered in patients with gastrointestinal bleeding of unknown etiology. In this case, the lesion was taken into account preoperatively, based on color Doppler ultrasonography and angiography. The best results of treatment can be achieved with resection, but it has to be performed before an eventual portal hypertension takes place.

Pancreatic arteriovenous malformation with portal hypertension

A 45-year-old man with recurrent episodes of hematemesis caused by extensive varices in the esophagus and stomach was admitted. He had a history of liver cirrhosis with hepatitis C virus infection. Computed tomography revealed a conglomeration of small strong nodular stains in the pancreatic head. Angiography revealed a racemose vascular network at the same site and early appearance of the portal venous system in the arterial phase. With a diagnosis of pancreatic arteriovenous malformation with portal hypertension, he underwent pylorus-preserving pancreaticoduodenectomy, preceded, 2 days earlier, by transcatheter arterial embolization of some of the feeding arteries. The varices observed preoperatively in the esophagus and stomach disappeared, and he has been well for 6 years after the operation. We reviewed 47 cases of pancreatic arteriovenous malformation previously reported in the English-language literature, with a focus on the clinical manifestations, treatment approaches, and etiological relationship with portal hypertension and liver cirrhosis.

Haemobilia

BACKGROUND

This review aims to establish whether increased use of invasive procedures and the trend toward conservative management of major trauma has resulted in an increased incidence of haemobilia.

METHOD

A Medline (http://igm.nlm.nih.gov/)-based search of the English language literature from January 1996 to December 1999 inclusive was performed using the keywords haemobilia, hemobilia, haematobilia and hematobilia. The presentation, aetiology, investigation, management and outcome of 222 cases were reviewed.

RESULTS

Two-thirds of cases were iatrogenic while accidental trauma accounted for 5 per cent. Haemobilia may be major, constituting life-threatening haemorrhage, or minor; it may present many weeks after the initial injury. Diagnosis is most commonly confirmed by angiography. Management is aimed at stopping bleeding and relieving biliary obstruction; 43 per cent of cases were managed conservatively and 36 per cent were managed by transarterial embolization (TAE). Surgery was indicated when laparotomy was performed for other reasons and for failed TAE. The mortality rate was 5 per cent.

CONCLUSIONS

Although the incidence of iatrogenic haemobilia has risen considerably, the bleeding is often minor and can be managed conservatively. When more urgent intervention is required, TAE is usually the treatment of choice. There is no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia.