A rare case of gastroduodenal artery pseudoaneurysm-related obstructive jaundice treated by endoscopic ultrasound-guided biliary drainage

Abstract

A pseudoaneurysm is defined as an arterial vessel with a defect in at least part of the vessel wall, leading to periarterial contained hematoma formation and an increased risk of rupture. Visceral pseudoaneurysms are often discovered incidentally or present with nonspecific symptoms such as vague abdominal pain, nausea, or vomiting.¹ According to previous retrospective studies, atherosclerosis, abdominal trauma, infection/inflammation, and complications of pancreatitis are well-established etiologies for visceral pseudoaneurysms.²

In this article, we present a case of 42-year-old man who had a gastroduodenal artery (GDA) pseudoaneurysm at the pancreatic head, initially manifesting as obstructive jaundice and severe abdominal pain. He had been a heavy alcohol consumer for 15–20 years, with a weekly consumption of 20–25 units of alcohol, but denied any history of acute pancreatitis. Upon triage, his vital signs were stable without hypertension. Laboratory data revealed direct-type hyperbilirubinemia, elevated liver enzymes, and marginal leukocytosis. Computed tomography (CT) of the abdomen showed a large tubular structure with adjacent hematoma formation at the pancreatic head, causing dilated intrahepatic and common hepatic duct (Figure 1). Initially, endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage was performed but failed due to difficult cannulation. Subsequently, percutaneous gallbladder drainage (PTGBD) was performed on the same day. To improve the patient's quality of life, internal biliary drainage via endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) and anterograde biliary drainage was performed 1 week later to replace the external drainage. Under EUS guidance, a 19-gauge needle puncture of the dilated left intrahepatic bile duct, distant from the pseudoaneurysm, can be safely performed (Figure 2A). An anterograde cholangiogram identified an obstruction at the distal common bile duct caused by the pseudoaneurysm (Figure 2B). The pseudoaneurysm was definitively treated by transarterial coil embolization (Figure 2C,D). The total bilirubin level improved afterward (from 14.20 mg/dL to 4.51 mg/dL), and the patient was discharged in stable condition 3 weeks after the initial presentation.

To our knowledge, this is the first reported case demonstrating the successful application of EUS-guided biliary drainage as a salvage treatment after failed ERCP for obstructive jaundice caused by a GDA pseudoaneurysm. Obstructive jaundice caused by external compression of a GDA pseudoaneurysms is extremely rare. The use of EUS-guided biliary drainage by experienced practitioners can serve as a complementary first-line modality to ERCP in patients with obstructive jaundice caused by visceral pseudoaneurysm.³

Hsin-Yu Hsu: Case data collection and wrote the manuscript. Chia-Hsien Lin: Case provider and review of the manuscript. Hsiu-Po Wang: Review of the manuscript. Yu-Ting Kuo: Study design, case provider, and critical review of the manuscript.

The authors declare no conflicts of interest.

Verbal informed consent was obtained for this case report. Ethics committee approval is not necessary because this is a case image report. Nonetheless, the authors followed the principles of the Declaration of Helsinki throughout the writing process.