2018 Volume 60 Issue 3 Pages 230-236
A 46-year-old man was admitted to the hospital with acute abdominal pain. Abdominal palpation revealed epigastric tenderness without signs of peritoneal irritation. Abdominal contrast-enhanced computed tomography (CT) displayed a retroperitoneal hematoma with extravasation around the pancreatic head, while reconstructed CT images showed stenosis of the celiac axis. The patient was diagnosed with median arcuate ligament syndrome. Selective angiography of the superior mesenteric artery showed asymmetric dilation with slight extravasation from the posterior superior pancreaticoduodenal artery. The patient was successfully treated by performing transcatheter arterial embolization (TAE) using micro coils and was discharged on day 9 after admission. However, he was readmitted 7 days later with symptoms of nausea and vomiting. On upper gastrointestinal endoscopy, we discovered stenosis of the descending portion of the duodenum. Because his clinical symptoms were not severe, surgery was avoided and conservative treatment consisting of hyperalimentation and nasal gastric tube drainage was administered. His symptoms subsequently improved and he was discharged on day 45.
There are two potential causes of duodenal stenosis after TAE : compression by a hematoma or ischemia of the duodenal mucosa. Mucosal ischemia may be the result of either vascular obstruction caused by TAE or inflammation arising from a hematoma. In the present case, the hematoma showed a daily decrease in size and there was ample collateral circulation from the pancreaticoduodenal arcade. We therefore concluded that the primary cause of duodenal stenosis after the TAE was inflammation. This case suggests that duodenal stenosis after TAE may improve with conservative treatment if the surrounding inflammation resolves with reduction in size of the associated hematoma. Further investigation is needed to determine both the appropriate time course for conservative treatment and the indications for when surgery should be performed.
