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CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 334-336

Ruptured inferior mesenteric artery aneurysm: a case report


Cosultant Vascular Surgery, Vascular Surgery Department, Matarya Teaching Hospital, Cairo, Egypt

Date of Web Publication10-Feb-2020

Correspondence Address:
Assem Mohamed Herzallah
Matarya Teaching Hospital
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JMISR.JMISR_46_19

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  Abstract 


Among visceral artery aneurysms, inferior mesenteric artery aneurysm is the rarest. Although most cases are of degenerative etiology, a small fraction of these cases are caused by autoimmune diseases. We report a case of spontaneous retroperitoneal hemorrhage from a ruptured inferior mesenteric artery aneurysm in a 30-year-old patient with systemic lupus erythematosus, treated by ligation.

Keywords: MSC, MRCS, MD


How to cite this article:
Herzallah AM. Ruptured inferior mesenteric artery aneurysm: a case report. J Med Sci Res 2019;2:334-6

How to cite this URL:
Herzallah AM. Ruptured inferior mesenteric artery aneurysm: a case report. J Med Sci Res [serial online] 2019 [cited 2020 Apr 6];2:334-6. Available from: http://www.jmsr.eg.net/text.asp?2019/2/4/334/278064




  Introduction Top


Visceral arteries are rarely affected by aneurysms, with an incidence in the general population ranging from 0.1 to 2%[1]. The inferior mesenteric artery is the least common among them to be affected[2]. We present a case of inferior mesenteric artery aneurysm associated with systemic lupus erythematosus, which is the first of its kind, as no cases as such were found in the literature.


  Case Presentation Top


A 30-year-old female patient was admitted to the Nephrology Department with arthralgia, rising serum creatinine, and falling urine output. She had recently complained of appearance of malar rash and oral ulcers; her erythrocyte sedimentation rate and C-reactive protein were elevated, antinuclear antibody was positive, and rheumatoid factor was negative.

On physical examination, all peripheral pulsations were felt, and the abdomen showed no palpable mass. Ultrasonography revealed bilateral calyceal small kidney stones (right: 8 mm, left: 2.5 mm) and right ovarian cyst (4.4 cm × 4.3 cm).

Complete blood count showed hemoglobin of 7.5 g/dl; her serum creatinine level was 2.27 mg/dl, and urea level was 101 mg/dl. Her urine analysis showed granular and hyaline casts, and pus cells and red blood cells were 10–12 and 30–35/HPF, respectively. Protein in 24-h urine collection was 790 mg/500 ml. The patient was started on intravenous corticosteroids, diuretics, folic acid, and aspirin.

On the night of the third day after admission, the patient complained of abdominal pain of acute onset, followed by gradual abdominal distension. Examination revealed pallor, tachycardia (180 b/m), hypotension (70/40 mmHg), and acute abdomen. Hemoglobin concentration dropped to 3.9 g/dl.

Fluid resuscitation and blood transfusion were started, and an emergency computed tomographic scan was done and revealed large retroperitoneal hematoma, more on the left side, surrounding the left kidney and displacing it anteriorly and medially [Figure 1].
Figure 1: Retroperitoneal hematoma (yellow arrows) displacing the left kidney (white arrow).

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The patient underwent midline laparotomy with a transperitoneal approach; the retroperitoneum was explored starting from the aorta, as the source of bleeding was not clear at this point, although the left renal artery was suspected. The aorta, the superior mesenteric, and both renal arteries were intact with no abnormality. On exploring the inferior mesenteric artery, it showed two saccular aneurysms, both approximately 1 cm in diameter, with the proximal one (approximately 4 cm from the origin) being intact, whereas the distal one (approximately 7 cm from the origin) being ruptured [Figure 2].
Figure 2: Inferior mesenteric artery, with the aneurysm (arrow).

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At this point, the patient had received a massive blood transfusion (6 U of packed red blood cells in 2 h), and manifestations of coagulopathy started to appear; the decision was made to control the bleeding with no revascularization. The artery was ligated in place proximal to the first aneurysm, and distal to the second one. The abdomen was closed en mass.

The postoperative course was uneventful. Symptoms and signs of intestinal ischemia were sought, but fortunately never appeared.


  Discussion Top


Visceral arteries are rarely affected by aneurysms, but when they do, they can be fatal. Aneurysms of the inferior mesenteric artery are usually asymptomatic, discovered on ultrasonography or computed tomography scans of the abdomen, which explains the increasing incidence of those cases in the past few decades when these diagnostic modalities have become increasingly available [Table 1] and [Table 2].
Table 1: The incidence of visceral artery aneurysm[3]

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Table 2: Etiology of visceral artery aneurysms[3]

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Visceral artery aneurysm associated with systemic lupus erythematosus is very rare. Gastrointestinal involvement affects approximately 30% of patients with systemic lupus erythematosus. Anorexia, nausea, vomiting, and abdominal pain are common gastrointestinal manifestations of systemic lupus erythematosus. Vascular changes in these patients include thrombosis, vasculitis, and intimal or mural thickening and present with symptoms and signs of intestinal ischemia rather than hemorrhage[3].

Most reported cases of inferior mesenteric artery aneurysms are localized in the proximal trunk of inferior mesenteric artery, and close to half a cases are asymptomatic, whereas the other half present with a pulsatile abdominal mass, abdominal pain, low back pain, or like our case, hemorrhagic shock[4].

It is recommended to treat visceral artery aneurysms electively once discovered, even if asymptomatic, as this confers much lower morbidity and mortality. Recently endovascular intervention has become an option in treating these aneurysms. However, many of these aneurysms remain technically challenging and unsuitable for this option[5].

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stanley JC, Wakefield TW, Graham LM, Whitehouse WMJr, Zelenock GB, Lindenauer SM. Clinical importance and management of splanchnic artery aneurysms. J Vasc Surg 1986; 3:836–840.  Back to cited text no. 1
    
2.
Shanley CJ, Shah NL, Messina LM. Uncommon splanchnic artery aneurysms: pancreaticoduodenal, gastroduodenal, superior mesenteric, inferior mesenteric, and colic. Ann Vasc Surg 1996; 10:506–15.  Back to cited text no. 2
    
3.
Parvin SD, Earnshaw JJ, Joint Vascular Research Group. Rare vasculardisorders: a practcal guide to vascular specialist. 2005. p. 196.  Back to cited text no. 3
    
4.
Edogawa S, Shibuya T, Kurose K, Sasaki K, Tomita H. Inferior mesenteric artery aneurysm: case report and literature review. Ann Vasc Dis 2013; 6:98–101.  Back to cited text no. 4
    
5.
Tovar JR, Molina EM, Morales V, Sanjuanbenito A, Lobo E. Evolution of the therapeutic approach of visceral artery aneurysms. Scand J Surg 2007; 96:308–313.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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