Obstructive jaundice as a rare complication of multiple pancreaticoduodenal artery aneurysms due to median arcuate ligament syndrome: a case report and review of the literature

BACKGROUND

Obstructive jaundice has various causes, and one of the rarest is pancreaticoduodenal artery aneurysm (PDAA), which is often associated with celiac axis stenosis caused by median arcuate ligament syndrome (MALS).

CASE PRESENTATION

The patient was a 77-year-old Azeri woman who presented with progressive jaundice, vague abdominal pain, and abdominal distension from 6 months ago. The intra- and extrahepatic bile ducts were dilated, the liver's margin was slightly irregular, and the echogenicity of the liver was mildly heterogeneous in the initial ultrasound exam. A huge cystic mass with peripheral calcification and compressive effect on the common bile duct (CBD) was also seen near the pancreatic head, which was connected to the superior mesenteric artery (SMA) and had internal turbulent blood flow on color Doppler ultrasound. According to the computed tomography angiography (CTA) findings, the huge mass of the pancreatic head was diagnosed as a true aneurysm of the pancreaticoduodenal artery caused by MALS. Two similar smaller aneurysms were also present at the huge aneurysm's superior margin. Due to impending rupture signs in the huge aneurysm, the severe compression effect of this aneurysm on CBD, and the patient's family will surgery was chosen for the patient to resect the aneurysms, but unfortunately, the patient died on the first day after the operation due to hemorrhagic shock.

CONCLUSION

In unexpected obstructive jaundice due to a mass with vascular origin in the head of the pancreas, PDAA should be considered, and celiac trunk should be evaluated because the main reason for PDAA is celiac trunk stenosis or occlusion by atherosclerosis or MALS. The treatment method chosen (including transarterial embolization, open surgery, or combined method) depends on the patient's clinical status and radiological findings, but transarterial embolization would be safer and should be used as a first-line method.

Serum homocysteine in deep venous thrombosis, peripheral atherosclerosis and healthy Iranians: a case-control study

This study was aimed to evaluate the association of serum homocysteine with peripheral atherosclerosis and deep vein thrombosis in an Iranian population complaining from vascular symptoms in lower limbs referred to a university general hospital in the capital of Iran. The study design was case-control. Deep vein thrombosis and atherosclerosis groups were, respectively consisted of 25 patients presenting with signs and symptoms of deep vein thrombosis whom disease was confirmed by duplex ultrasonography and 25 patients presenting with signs and symptoms of chronic arterial insufficiency who were candidate for arterial reconstruction whom disease was confirmed by angiography. The control group was consisted of 25 persons selected among relatives accompanying the traumatic patients admitted in the general surgery ward of the same hospital. The age of atherosclerosis, DVT and control group were 61 +/- 14, 47 +/- 16 and 40 +/- 14, respectively. The serum level of homocysteine was higher in males (p < 0.01) except for atherosclerotic patients. The prevalence of high homocysteine was 15% (control), 36% (DVT) and 56% (atherosclerosis) among females and 75% (control), 73% (DVT) and 56% (atherosclerosis) among males. The serum homocysteine in the control group which was representative of Tehran population who do not take vitamin B supplements was unexpectedly high. It seems that fortification of popular foodstuffs should be considered for Tehran. The association between homocysteine and atherosclerosis and deep vein thrombosis was not confirmed in this study especially for men who had higher serum homocysteine than women. It is possible that this association fades away in populations with high prevalence of hyperhomocysteinema.