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False aneurysm of the pancreaticoduodenal artery complicating therapeutic endoscopic retrograde cholangiopancreatography

¹ Department of Radiology, Central Middlesex Hospital, Acton Lane, London NW10 7NS ² Department of Diagnostic Radiology, St George's Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK

Correspondence: Dr P J Shorvon

	Abstract

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A 76-year-old woman underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures for palliation of a carcinoma of the pancreas. At the first procedure a pre-cut sphincterotomy was performed because deep cannulation of the biliary tree was impossible. An endoscopic plastic biliary stent was inserted at the second ERCP. The patient developed abdominal pain and a post-procedure CT demonstrated a psuedoaneurysm. This was not present on the pre-procedure CT and was thought to arise from the pancreaticoduodeal artery as a complication of the pre-cut sphincterotomy. Visceral angiography confirmed the origin of the aneurysm from a branch of the inferior pancreaticoduodenal artery. The aneurysm was successfully embolised. To our knowledge, this is the first time that this complication has been reported.

	Introduction

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Aneurysms of the pancreaticoduodenal artery and its branches are rare. Recognized causes include acute and chronic pancreatitis, surgery and connective tissue disorders [1–3]. The major complication of pancreaticoduodenal artery aneurysms is rupture, usually causing massive gastroduodenal haemorrhage with an associated high mortality. Therapeutic angiographic embolisation is the treatment of choice; surgery is reserved for those cases where this fails [3, 4].

Significant haemorrhage is one of the most feared complications of sphincterotomy at endoscopic retrograde cholangiopancreatography (ERCP) [5]. We present a case of a false aneurysm of the pancreaticoduodenal artery caused by sphincterotomy, which to the best of our knowledge is the first time this complication has been proven.

	Case report

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A 76-year-old woman presented with a 4-week history of painless jaundice, weight loss, dark urine and pale stools. Biochemical findings indicated obstructive jaundice. Ultrasound examination demonstrated a small mass in the head of the pancreas causing dilatation of both the biliary tree and the pancreatic duct. CT confirmed the ultrasound findings. An ERCP was performed 4 days later. There was narrowing of the proximal second part of the duodenum with normal overlying mucosa, but the papilla of Vater appeared to be infiltrated by tumour. Contrast medium injected into the common duct demonstrated a low short stricture. A small sphincterotomy was performed as a guidewire could not be passed through the stricture. As deep cannulation still could not be achieved, it was not possible to enlarge the sphincterotomy with a conventional sphincterotome. A pre-cut sphincterotome was therefore used to extend the sphincterotomy. It was possible to pass a guidewire through the stricture following this procedure, but on attempted stenting there were technical problems with the endoscope. Attempts to retain the wire in the bile duct whilst the endoscope was exchanged failed and the procedure had to be abandoned.

The patient was well following the procedure. Repeat ERCP 2 days later confirmed the initial findings. On this occasion the guidewire passed through the stricture with ease and the stricture was dilated to 10 F guage. A 5 cm 10 F gauge plastic endoprosthesis was then passed into position across the stricture without incident.

The patient remained jaundiced and developed a pyrexia following this second ERCP. Contrast enhanced CT performed 8 days later showed a satisfactory position of the biliary stent and resolution of the biliary dilatation. However, there was now a 5 cm mass situated within the pancreatic head, which became centrally enhanced during the arterial phase (Figure 1). This was diagnosed as a false aneurysm, presumably related to the pancreaticoduodenal artery and a complication of the previous ERCPs. The diagnosis of a false aneurysm arising from a branch of the inferior pancreaticoduodenal artery was confirmed at angiography. The aneurysm was successfully embolised with polyvinyl alcohol and a single microcoil (Figure 2). Her pain settled and follow-up CT demonstrated thrombosis of the aneurysm. She was discharged 2 weeks later.

View larger version (53K): [in this window] [in a new window]   Figure 1. Enhanced spiral CT during the arterial phase. (a) Pre-endoscopic retrograde cholangiopancreatography (ERCP) through the head of the pancreas. No aneurysm is seen. (b) Post-ERCP, a pseudoaneurysm with layering of contrast medium is seen.

View larger version (77K): [in this window] [in a new window]   Figure 2. Selective superior mesenteric angiograms. (a) Pre-embolisation: a pool of contrast medium (arrow) adjacent to the biliary stent lies within an aneurysm arising from the inferior pancreaticoduodenal artery. (b) Post-embolisation: there is no filling of the inferior pancreaticoduodenal artery or aneurysm. A coil is noted within this vessel (arrow).

	Discussion

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Other common complications of sphincterotomy are retroperitoneal perforation and bleeding. The former occurs in about 1% of sphincterotomies, is usually recognized at the time by leakage of gas or contrast medium, but may require CT for definitive diagnosis, and is normally treated conservatively. Significant haemorrhage occurs after about 2% of sphincterotomies. The reason for the low rate of bleeding is probably because the vessels in the arterial plexus around the papilla are small. The pancreaticoduodenal artery crosses the bile duct on average 3.75 cm from the tip of the papilla, well out of the range of a sphincterotomy. However, in 4% of autopsy specimens examined this artery was within range of the sphincterotomy and it is probably this small group of patients who are at risk of haemorrhage [6]. Haemorrhage can often be treated conservatively or by adrenaline injections, but a few cases will require surgery or angiographic intervention.

In pre-cut sphincterotomy with a needle knife (pre-cut sphincterotome), an incision is made into the common channel of the bile duct and pancreatic duct or the bile duct itself, without deep biliary cannulation. This technique is said to be associated with an increased complication rate of perforation, haemorrhage and pancreatitis because it is less controlled than standard sphincterotomy, but this is disputed by expert centres [5, 7, 8].

Pancreaticoduodenal aneurysms (PDAs) are rare, accounting for 1–2% of all visceral aneurysms, and there are only 88 reported cases in the world literature [3]. True PDAs are usually associated with stenosis of the coeliac axis [9], whereas false PDAs occur as a complication of pancreatitis. Mycotic PDAs have been described as a complication of bacterial endocarditis.

False aneurysms occur as a result of damage to the wall of an artery. In our case this probably occurred during needle knife sphincterotomy, and to our knowledge is the first time this complication has been reported following ERCP. An aneurysm of the gastroduodenal artery has been reported following ERCP, but this was thought to be mycotic in origin, secondary to a bacteraemia induced by the procedure.

False PDA as a complication of pancreatitis usually arises from the superior pancreaticoduodenal artery, whereas in our patient it arose from the inferior pancreaticoduodenal artery. Furthermore, the rapidity with which the aneurysm arose and the lack of any clinical or radiological evidence of post-ERCP pancreatitis makes pancreatitis an unlikely aetiology. Most aneurysm formation secondary to pancreatitis is in association with pseudocyst formation.

Our patient rapidly developed a 5 cm aneurysm and urgent treatment was indicated to avoid rupture, which has a reported mortality of 49%. Surgical treatment, with a mortality of 19% [1], has been largely superceded by angiography and embolisation, which has a lower procedure mortality and high success rate [10, 11]. This approach had a successful outcome in 15 of 19 patients (79%) with peripancreatic aneurysms [12].

This report documents that pseudoaneurysm formation is a potential complication of endoscopic sphincterotomy, and we advise urgent referral for angiographic embolisation in this situation to avoid aneurysm rupture.

Received for publication September 5, 2000. Revision received November 24, 2000. Accepted for publication December 5, 2000.

	References

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