An Unruptured Jejunal Aneurysm in a Female Patient with Melena Caused by Arteriovenous Malformation
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An Unruptured Jejunal Aneurysm in a Female Patient with Melena Caused by Arteriovenous Malformation Zeyang Chen 1 & Zining Liu 1 & Jianqiang Tang 1 Received: 30 July 2020 / Accepted: 8 August 2020 # 2020 The Society for Surgery of the Alimentary Tract
A 56-year-old woman presented with intermittent melena associated with fatigue for a year without any inducement. Laboratory tests indicated iron-deficiency anemia with a decreased hemoglobin level of 9 g/dL (normal range, 11.6–15.5 g/dL) and a positive result for fecal occult blood. Gastroscopy and colonoscopy were performed without any abnormal findings in the stomach, proximal duodenum, and colorectum. The three-dimensional volume rendering images of abdominal contrast-enhanced computed tomography (CT) (Fig. 1a) and superselective superior mesenteric artery (SMA) angiography (Fig. 1b) show a 1.8-cm-diameter unruptured aneurysm that was located at the first jejunal artery (J1) with multiple ectasias of its distal. An exploratory laparotomy was performed. The aneurysm (black arrow) is close to the proximal jejunum, and there are vast dilated subserosal vessels along the related intestinal segment (white arrow) (Fig. 1c). Because of the lack of evaluation of the small intestinal lumen preoperatively, a technique combining intraoperative enteroscopy with methylene blue injection via J1 and focused enterectomy (Fig. 1d) is applied in this case. The enteroscopy reveals that there were multiple hemorrhagic spots (black arrow) in the mucosa of the jejunum fed by J1 (Fig. 2a), as well as blue submucosa in the focused intestinal segment (Fig. 2b). The pathological examination was consistent with arteriovenous malformation (AVM). Histopathological findings of
* Jianqiang Tang [email protected] 1
Department of General Surgery, Peking University First Hospital, Peking University, 8 Xi ShiKu Street, Beijing 100034, People’s Republic of China
sections with H&E and Elastica van Gieson staining show that there were thrombi in irregular vessels with thickened walls (Fig. 2c) and multifocal destruction of the elastica layer and hyperplasia of the intima (black arrow) (Fig. 2d). Follow-up of 5 years later showed no symptom of melena and normal level of hemoglobin (12.3 g/dL). Patients with unruptured visceral artery aneurysms are usually asymptomatic; however, chronic iron-deficiency anemia is a common symptom for gastrointestinal AVM, which is a rare lesion consisting of abnormal shunts between the arterial and venous systems.1 High-flow AVM can increase wall shear stress, which may cause the formation of aneurysms in cerebral small vessel feeders.2 This mechanism may also apply in our case, which, to our knowledge, is the first case to report a jejunal AVM feeder with an aneurysm. Michel et al. indicated that the incidence of intracranial arterial aneurysms in the population with AVM was higher than in the population at large.3 The visceral arterial aneurysm can easily be discovered by preoperative imaging examinations; however, small intestinal AVM can hardly
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