Case report of a successful non-operative management of postoperative bleeding from pseudoaneurysm of the gastroduodenal artery, following gastric surgery

INTRODUCTION: Post operative pseudoaneurysm of the gastroduodenal artery is a very rare entity. Rupture of the pseudoaneurysm can be treated by embolism of the artery. PRESENTATION OF CASE: A 71 years old male with a perforated pyloric ulcer was treated with controlled external duodenal fistula. Due to postoperative bleeding a subtotal gastrectomy was performed. A second episode of bleeding occurred and rupture of a pseudoaneurysm of the gastroduodenal artery was diagnosed by computed angiography and treated by embolism of the artery. Three days later the duodenal stump was ruptured and a new controlled external duodenal fistula was surgically created. The patient died 6 weeks later due to multiple organ failure. DISCUSSION: Pseudoaneurysm is the result of self-contained ruptures of one or more layers of the vascular wall. Computed angiography is the golden standard to identify pseudoaneurysms (100% sensitivity). Early suspicion for the presence of a pseudoaneurysm is crucial, as when the rupture actually occurs, the mortality rate is remarkably high. Endovascular approach is a minimally invasive procedure with high success rates (70-100%) and significantly lower morbidity and mortality rates. Surgical is reserved in case of bleeding recurrence. The fact that is particularly interesting in this patient is the timing of the formation of the pseudoaneurysm, considering the fact that 48 h earlier the gastroduodenal artery appeared normal. CONCLUSION: There are no guidelines regarding the treatment of the pseudoaneurysm of the gastroduodenal artery. It seems reasonable to treat them immediately after diagnosis because a possible rupture of the aneurysm has an extremely high mortality.