The rare case of a symptomatic atherosclerotic aneurysm of the superior epigastric artery mimicking an acute cholecystitis
Article Outline
True aneurysms of the epigastric artery are rare. We report a case of a 65-year-old female who was admitted for increasing upper abdominal pain. A leukocytosis, pyrexia, breathing stop on inspiration, and a palpable mass next to the right costal arch with severe local pain were suspicious for acute cholecystitis. Surprisingly, sonography and CT scan revealed a 5 x 4 cm structure limited to the abdominal wall directly above the gallbladder, which showed an arterial flow in the duplex scan. After resection and an uneventful postoperative course, the histological findings confirmed the diagnosis of a symptomatic true atherosclerotic aneurysm.
Aneurysms of the epigastric arteries are rare. Systematic Medline search (key words: epigastric, aneurysm, pseudoaneurysm, false aneurysm, abdominal wall, trauma) combined with a review of the references of each article provided not a single report of a true atherosclerotic aneurysm while there are some reports of mostly traumatic pseudoaneurysms of the inferior epigastric artery.
Case report
A 65-year-old female patient was admitted to the hospital because of severe pain progressing for hours in the right epigastic region. She had never had similar symptoms before. As a result of repeated vomiting, she showed signs of dehydration. Clinical examination revealed pain next to the right costal arch with signs of regional peritonitis, stop of breathing on inspiration, and a palpable swelling despite the obesity. The body temperature was increased to 38.2°C. The laboratory analysis showed a WBC-count of 14.8 GPt/l, and the CRP elevated to 17.9 mg/l. Subnormal serum potassium and a slightly increased γGT were noticed. The ECG showed a sinus rhythm with tachycardia of 115/min and a left anterior hemi blockage. Her personal history was remarkable for hypercholesterolemia, arterial hypertension, and obstructive lung disease.
While excluding cholecystolithiasis, the ultrasound surprisingly revealed a 5 x 4 cm mass limited to the abdominal wall directly above the gallbladder, which had an arterial flow in the duplex scan with a cranio-caudal direction. The CT scan (Fig 1) confirmed the diagnosis of an aneurysm of the right superior epigastric artery bulging out the posterior leaflet of the rectus sheath, tangent to the surface of the gallbladder. Due to pain and signs of local inflammation operative intervention was indicated.
Fig 1.
CT-Scan with contrast enhancement.
Using a paramedian incision just above the palpable swelling, the aneurysm was displayed. The proximal and distal sections of the epigastric artery were heavily kinked (Fig 2). Surrounding tissue showed signs of inflammation. The aneurysm was resected including the kinked portions of the artery. The proximal and distal artery was ligated (Fig 3). The wound healing was uneventful, and the patient could be discharged at the fifth postoperative day. The histological examination revealed the diagnosis of a true atherosclerotic aneurysm with a diameter of 5 cm and a severe calcifying arteriosclerosis (Fig 4).
Fig 2.
The surgical exposure.
Fig 3.
The resected and incised aneurysm.
Fig 4.
Aneurysm wall and proximal artery with typical atherosclerotic changes. Freshly ruptured plaque with bleeding signs and old calcifications as well as cholesterol crystals and fibrotic and sclerotic wall thickness, no evidence for arteritis, mycotic aneurysm, or other diseases like Behcet’s disease.
Discussion
In the 15 reports of pseudoaneurysms of the inferior epigastric artery available, seven were caused by sutures after laparotomy, four by an incidental puncture during paracentesis or surgical drain placement, one by a laparoscopic trocar, one while implanting a catheter for continuous ambulatory peritoneal dialysis, and two were spontaneous.1, 2, 3, 4, 5 Different types of treatment were reported: the resection of the aneurysm with arterial ligation, percutaneous ultrasound guided thrombin, injection, or percutaneous coil embolization.6
In this case, we preferred the complete resection of the aneurysm due to potential complications and local inflammation. The rectus muscle is easily supplied by collaterals even if the artery is ligated or resected over a longer distance. The patient could not remember either a puncture or a trauma. The pathologist confirmed the first case of a true symptomatic atherosclerotic aneurysm of the right superior epigastric artery. There was no evidence of mycotic aneurysm or arteritis or Behcet’s disease. The local inflammation around the aneurysm and peritoneal irritation were mimicking an acute cholecystitis and were responsible for the clinical symptoms.
References
- Inferior epigastric artery false aneurysms: review of the literature and case report. Eur J Vasc Endovasc Surg. 2007;33:182–186
- . False aneurysm of the inferior epigastric artery as a complication of abdominal retention sutures. Surgery. 1973;74:460–461
- Pseudoaneurysm of the inferior epigastric artery: diagnosis and percutaneous treatment. Am J Roentgenol. 1990;155:529–530
- Pseudoaneurysm of the inferior epigastric artery: pathogenesis, diagnosis, and treatment. Arch Surg. 1996;131:102–103
- Pseudoaneurysm of the inferior epigastric artery. Acta Belg. 1997;97:196–198
- . Inferior epigastric artery pseudoaneurysm: ultrasound diagnosis and treatment with percutaneous thrombin. Br J Radiology. 2002;75:689–691
Competition of interest: none.
PII: S0741-5214(07)00519-8
doi:10.1016/j.jvs.2007.03.042
© 2007 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
