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A rare cause of gi bleedingResident: Emily N. Kinsey MDAttending: David R. Sopko MDProgram/Dept: Duke University Medical Center

Correct!1) What variant anatomy is present?

Replaced left hepatic artery. A left hepatic artery replaced to the left gastric artery originates from the left gastric artery and is the only artery that supplies the left hepatic lobe. Replaced right hepatic arteryThis variant arterial supply is technically a right hepatic artery replaced to the SMA. It originates from the SMA, andsupplies the right lobe. Accessory left hepatic arteryThis would be correct if a normal left hepatic artery waspresent in addition to the branch from the left gastric. Artery of DrummondThis provides a connection between thebranches of the SMA and IMA

CONTINUE WITH CASERelevant HistoryPast Medical HistoryDiabetesPast Surgical HistoryMultiple abdominal surgeries after perforated jejunal ulcerPercutaneous gastrostomy tube for nutritionMedicationsOmeprazole Metformin

PMH go in HPI. DM etc. 3Diagnostic WorkupPhysical ExamHeart rate 130Blood pressure 116/77Epigastric tendernessLaboratory DataHb 9.3, down trendingNon-Invasive ImagingCT scan performed prior to transfer was uploaded to PACSCT scan from the outside hospitalWall thickening around the second portion of the duodenum is consistent with history of multiple ulcerations in that area. Enhancing lesion that was located immediately adjacent to the jejunal branch of the SMVThis differential diagnosis at this time included a hypervascular mass or a pseudoaneurysm.

Intervention: Celiac arteryArteriogram with possible embolizationMicropuncture set was used to access the right common femoral artery. 5 French vascular sheath was placed. Bentson wire and a Mikaelsson catheter were advanced to the celiac artery. Celiac arteriogram was performed.

Question Slide1) What variant anatomy is present?A: Replaced left hepatic arteryB: Replaced right hepatic arteryC: Accessory left hepatic arteryD: Artery of Drummond

Use series 1b7INCorrect1) What variant anatomy is present?

Replaced left hepatic artery. A left hepatic artery replaced to the left gastric artery originates from the left gastric artery and is the only artery that supplies the left hepatic lobe. Replaced right hepatic arteryThis variant arterial supply is technically a right hepatic artery replaced to the SMA. It originates from the SMA, andsupplies the right lobe. Accessory left hepatic arteryThis would be correct if a normal left hepatic artery waspresent in addition to the branch from the left gastric. Artery of DrummondThis provides a connection between thebranches of the SMA and IMA

CONTINUE WITH CASEQuestion2) What is your next step?A: Embolize the feeding artery with alcoholB: Occlude pseudoaneurysm with coilsC: Inject the IMAD: Inject a provocative agent (ex. nitroglycerin) to confirm active extravasation.

Diagnosis: Hypervascular solid massNotice the timing of enhancement of the lesion. It is delayed from the arterial phase but before the portal venous phase. The enhancement pattern follows the solid organs. There is homogenous, uniform filling of contrast. Notably absent is swirling of contrast as would be seen in a pseudoaneurysm.

Diagnosis: Hypervascular solid massHere is a magnified view of the mass.

There are many small vessels coursing through it. It is a well defined, round mass. COMPANION case: pseudoaneurysmContrast the round, solid mass to this oblong pseudoaneurysm. A pseudoaneurysm will enhance with the arterial phase. If it is partially thrombosed, it will not fill completely. There is heterogeneous filling and swirling of contrast.

COMPANION case: active bleedingActive hemorrhage will cause extravasation of contrast. The contrast will appear to enlarge and diffuse away from the feeding vessel. It will not appear as a well defined, round or oval mass. Instead, you may see contrast pooling in the extravascular space.False negatives can occur when there is intermittent bleeding or when the rate of bleeding is below angiographic threshold for detection (o.5 ml/min).

Clinical Follow UpGastrin level was 332 (normal is