A case of pancreatic arteriovenous malformation associated with the ulcer at the descending part of duodenum

Abstract

A 45-year-old man was admitted to our hospital with the symptom of epigastric pain. Laboratory data on admission was unremarkable.
Esophagogastroduodenoscopy showed ulcer, which had exposing vessel at the anal side of papilla Vater. In spite of the medical therapy by fasting and prescription of proton pump inhibitor (PPI) for 6 days, epigastric pain persisted and duodenal ulcer did not heal. Abdominal helical dynamic CT showed nodular hypervascular lesion in the pancreatic head, and early filling of portal vein in early phase. Abdominal arterial angiography showed the similar finding to that of dynamic CT : a racemose intrapancreatic vascular network, and early filling of portal vein. Based on the result of CT and angiography, we made a diagnosis of pancreatic arteriovenous malformation (AVM), and subsequently pylorus-preserving pancreatoduodenectomy (PpPD) was done after arterial embolization. Macroscopic findings of resected specimen showed ulcer at the anal and pancreatic side of papilla Vater, and erosion around the ulcer. Pathology of specimen showed venous vasodilation and rupture of the elastic fibers, both of which findings were consistent with pancreatic AVM. Pancreatic AVM is a rare entity and the duodenal ulcer at the descending part accompanied by pancreatic AVM is much less ; there has been only 25 reports in Japan. Duodenal involvement in pancreatic AVM often develops ulcer and bleeding. Therefore, these patients usually complain of epigastric pain and melena. This case report indicated that pancreatic AVM is one of the differential diagnosis in patients with intractable duodenal ulcer.