Pseudoaneurysm represents a rare complication in chronic pancreatitis, caused by enzymatic digestion of peripancreatic arteries or the erosion of a visceral artery by pseudocysts. The presence of multiple pseudoaneurysms is rarely seen and their association with splenic infarction has been rarely reported. This case presentation reports the concomitant presence of two pseudoaneurysms with different mechanisms of formation, one of them diagnosed by EUS features and histology of pseudotumoral chronic pancreatitis; the second was diagnosed by contrast-enhanced transabdominal US and CT scan. Their association with splenic infarction was explained by ischemic pathogenesis.

Splenic artery aneurysm is the most common aneurysm of visceral vessels. Their rupture usually leads to massive bleeding, being a direct life threat. Splenic artery aneurysms usually rupture into the free peritoneal cavity, and much less frequently into the lumen of the gastrointestinal tract.We describe the case of a 38-year-old male patient, who, as a result of chronic pancreatitis, developed a false aneurysm of the splenic artery, which initially caused necrosis of the large intestine and bleeding into its lumen, and subsequently necrosis of the posterior stomach wall with the aneurysm rupture to the stomach lumen with a dramatic course.The case described confirms that splenic artery aneurysm can be a cause of bleeding to both upper and lower parts of the gastrointestinal tract, and the aneurysm rupture is usually of a dramatic and life-threatening course.

Visceral artery pseudoaneurysms are uncommon. They most commonly affect the splenic artery and are secondary to chronic pancreatitis. Giant pseudoaneurysms (5 cm or larger in size) are rare and, until now, only 19 cases have been reported.A 47-year-old chronic alcoholic and diabetic male presented with upper abdominal pain of 1-month duration without any other significant complaint. Computed tomography was performed which revealed features of chronic pancreatitis along with a splenic artery pseudoaneurysm measuring 7x4 cm in size. As the disease was confined to the body and tail of the pancreas, the patient underwent a distal pancreatectomy and splenectomy along with resection of the pseudoaneurysm with an uneventful postoperative course.Splenic artery pseudoaneurysms, especially the giant variety, are uncommon. As they are most commonly secondary to chronic pancreatitis, they are better managed surgically which resolves the pseudoaneurysm as well as its underlying cause (i.e. chronic pancreatitis).

Gastroepiploic artery aneurysm (GEAA) is very rare.1 Furthermore, most GEAA cases are diagnosed after their rupture. We report a case of asymptomatic GEAA. The patient was a 61-year-old man. Sonography (US) revealed a 2-cm anechoic mass in the epigastrium near the anterior abdominal wall. Color Doppler US and contrast-enhanced US showed arterial flow within the mass leading to the diagnosisof visceral artery aneurysm. CT and angiography confirmed the diagnosis of right GEAA, and the aneurysm was treated successfully with embolization. Follow-up US 6 months later confirmed the absence of blood flow within the lesion.

Massive haemobilia carries a mortality of 25% in most reports. Although previously it was mainly due to road accidents or homicidal attempts it is now more often due to iatrogenic trauma like percutaneous liver biopsy and biliary drainage. However the management protocol is not established and there have been few reports of this serious condition from India.To review the causes of massive haemobilia and outline its management in an Indian hospital.We retrospectively analysed the records of 20 consecutive patients with massive haemobilia (blood requirement more than 1400 ml/day) admitted to our department over six years from a prospectively maintained database. There were 10 males and 10 females who had a mean age of 43 (range 15-65) years.Haemobilia accounted for 9 percent of patients admitted with upper gastrointestinal bleeding who were seen over this period. The commonest cause was iatrogenic (11) including laparoscopic cholecystectomy (6), Whipple's operation, endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), hepatic stone extraction and removal of biliary stent (1 each). The others had accidental trauma (4), visceral aneurysms (2), biliary stones (2) and chronic pancreatitis (1). The commonest clinical presentation was massive gastrointestinal bleeding. The dual phase computed tomography (CT) scan correctly identified the site of bleeding and other associated conditions in all the 11 patients in whom it was done. Conventional angiography was done in 8 patients with transarterial embolisation (TAE) being attempted in 6 and successful in 2 patients. Operations were performed in 18 patients for the following indications - failure of angiographic embolisation (6), failure of endoscopic sclerotherapy (EST) (1), duodenal erosion (2), portal biliopathy (1), haemoperitoneum (1), bile leak (1), pseudocyst (1), liver necrosis (1) and other hepatobiliary conditions (4). The surgical procedures to control bleeding were ligation of aneurysms (8), repair of the hepatic artery (4), right hepatectomy (3), lienorenal shunt, cholecystectomy and under-running of the duodenal papilla (1 each). The overall mortality was 4 patients (20 percent). There was no mortality in patients with bleeding aneurysms; the mortality being significantly higher in patients with non-aneurysmal bleeding (p=0.0049: Fishers' exact test).In our experience haemobilia was usually due to an iatrogenic cause with a pseudoaneurysm following a diagnostic or therapeutic intervention(most often laparoscopic cholecystectomy) being the commonest aetiology. A dual phase CT scan accurately identified the site of bleeding. Angiographic embolisation often failed to stop bleeding and mortality was significantly higher in patients with non-aneurysmal bleeding. We should perhaps consider early surgery for haemobilia once the bleeding site has been localised by CT scan.

This article reports a patient with acute intra-abdominal hemorrhage secondary to a rare vascular disease, segmental arterial mediolysisThe patient was a 56-year-old female who presented with severe acute abdominal pain. An abdominal and pelvic computed tomogram demonstrated suggestion of an intra-abdominal hemorrhage. Visceral angiography illustrated aneurysms in the branches of the inferior mesenteric artery. The patient underwent a left hemicolectomy with resection of the diseased artery.The angiographic and histologic findings were consistent with a diagnosis of segmental arterial mediolysis involving only the inferior mesenteric artery.This is the first known reported case of intra-abdominal hemorrhage related to segmental arterial mediolysis requiring emergent hemicolectomy.

Hemorrhage from the pancreatic duct, i.e. hemosuccus pancreaticus (HP), is a rare cause of gastrointestinal bleeding. Pancreatic hemosuccus is usually due to the rupture of an aneurysm of a visceral artery, most likely the splenic artery, in chronic pancreatitis. Other causes of HP are rare. We present a case of HP in a female patient with no history but with positive findings of chronic calcifying pancreatitis upon ultrasonographic investigation, computed tomography scan, and endoscopic retrograde cholangiopancreatography. With detectable fresh blood in the descending duodenum, angiography of the celiac artery revealed an aneurysm of the splenic artery as the suspected cause of intermittent bleeding from the pancreatic duct. The treatment is traditionally surgical or by interventional radiological means. This is the first case described in the literature in which interventional radiological therapy involved implantation of an uncoated metal Palmaz stent in the splenic artery. In the follow-up of 18 months no relapse of HP was observed.

A 51 year old male patient with a history of chronic alcohol consumption and recurrent pancreatitis was referred to our hospital with jaundice, epigastric pain, severe diarrhoea and weight loss of 28 kg within the last 12 months. A CT scan of the abdomen 4 months before admission had shown a pancreatitis with free fluid around the corpus and tail of the pancreas as well as dilated intrahepatic bile ducts and a cavernous transformation of the portal vein. Moreover, a tumor (3.5 x 3.0 x 3.6 cm) with irregular contrast enhancement was seen within the left liver lobe. The patient was referred to us for further evaluation and treatment. The initial B-Mode sonogram revealed a bull's eye like well defined lesion (8.1 x 7.5 x 7.0 cm) within the left liver lobe, consistent with a tumour or abscess. Prior to a diagnostic needle biopsy a PTCD was performed in this case presenting with dilated intrahepatic bile ducts and having a history of Billroth II operation. An additional colour coded Duplex Doppler ultrasonography demonstrated a visceral artery aneurysm and prevented us from performing the diagnostic puncture. The aneurysm was assumed to originate from a variant or a branch of the left hepatic artery. Angiography revealed a pseudoaneurysm of the pancreaticoduodenal artery and coil embolization was performed because of the increasing size and the risk of a bleeding complication. Postinterventional colour duplex ultrasound measurement showed no blood flow within the aneurysm. Retrospectively, the pseudoaneurysm must have led to a compression of the common bile duct, since the patient did not develop cholestasis after embolization and removal of the PTCD. Thus, a pseudoaneurysm of the pancreaticoduodenal artery must be included in the differential diagnosis of liver tumours in patients with chronic pancreatitis, despite its unusual localization near the liver. Therefore, we suggest that colour coded ultrasonography should be applied to any unclear, bull's eye like lesion, even though this method alone cannot exactly determine the origin of the pseudoaneurysm. Interventional angiography remains the gold standard for the diagnosis and therapy of visceral artery aneurysm.

Acute hemorrhage due to a pseudocyst of the pancreas is a dangerous complication of chronic pancreatitis (CP). Without operative treatment, mortality is as high as 90%. Immediate recognition of this complication as well as urgent operative treatment allowing the survival of 70% of patients is imperative. Described is the case of a patient with CP and pseudocyst in which hyperamylasemia and unclarified anemia developed following sudden abdominal pain. The suspicion of hemorrhage into the peritoneal cavity was confirmed by selective visceral angiography showing hemorrhage from the splenic artery in the region of the hilus of the spleen. Operative treatment was successful. During the procedure, a ligature was applied to the hemorrhaging splenic artery and a splenectomy was carried out with 2500 ml of bloody contents being removed from the abdominal cavity. Acute hemorrhage into the peritoneal cavity as a complication of chronic pancreatitis with pseudocyst (CPP) requires immediate identification, confirmation by visceral angiography, and urgent operative treatment.