Pancreaticoduodenal artery aneurysm associated with polyarteritis nodosa presenting as massive upper gastrointestinal bleeding.

The pancreaticoduodenal arteries are rare sites for true aneurysm formation, but these may develop in association with occlusion of the coeliac circulation, degenerative conditions or inflammatory vascular disorders. These have a high risk of rupture regardless of size or other factors. One identified cause is polyarteritis nodosa (PAN), which is an autoimmune necrotising vascular condition that affects small-sized and medium-sized arteries. We report a case of a 40-year-old man with massive gastrointestinal tract bleeding from a ruptured pancreaticoduodenal artery aneurysm secondary to PAN. This was managed with emergent open aneurysm ligation followed by high-dose corticosteroids and cyclophosphamide pulse therapy. Only three other cases of PAN-associated pancreaticoduodenal artery aneurysms have been reported in the literature.

Duodenal perforation secondary to stent migration after ERCP for hepatobiliary tuberculosis: Case report of a lethal complication in a young patient.

INTRODUCTION: Interventional internal drainage of the biliary tract has become an established procedure for the temporary and definitive treatment of biliary obstruction due to malignant or benign disease. The complication rate is reported to be so low that when feasible, this technique is preferred over a surgical drainage procedure. PRESENTATION OF A CASE: A 26-year old woman was referred to the hepatopancreaticobiliary surgery service due to severe abdominal pain for 3 days after undergoing endoscopic retrograde cholangiopancreatography (ERCP). She underwent biliary dilatation and stent insertion for obstructive jaundice secondary to biliary stricture from hepatobiliary tuberculosis. The patient underwent exploratory laparotomy, peritoneal lavage, duodenorrhaphy and tube jejunostomy for bilious peritonitis and duodenal perforation from biliary stent migration. The patient died one day post-operation due to septic shock from secondary bacterial peritonitis. DISCUSSION: ERCP and other interventional endoscopic biliary interventions are increasingly being used for biliary obstruction. Despite the various complications which arise from these diagnostic and therapeutic modalities, complications are relatively uncommon. Duodenal perforation from biliary stent migration is a rare complication after undergoing ERCP and stenting. However, in patients presenting with severe pain and physical signs of acute abdomen after the procedure, it should always be a consideration. CONCLUSIONS: Despite the relative safety of interventional techniques for biliary obstruction, complications like pancreatitis, hemorrhage and perforation may occur. Early recognition and high index of suspicion allows for early intervention with good outcomes. Duodenal perforation from stent migration can occur and when intervention is delayed may lead to morbidity and mortality.