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A Case of Segmental Arterial Mediolysis Presenting as Mucosal Gastric Hematoma
Shunsuke Sakuraba1, Hajime Orita1, Shuhei Ueda1
1Department of Surgery, Juntendo Shizuoka Hospital, Shizuoka, Japan.
Background:
Although segmental arterial mediolysis (SAM) has been increasingly recognized as arteriopathy and there are some case reports about SAM, it is still very rare. It is characterized clinically by aneurysm, dissection, stenosis, and occlusion within splanchnic arterial branches, causing intra-abdominal hemorrhage or bowel ischemia. Mortality is as high as 50% in acute events.
Case Presentation:
A 51-year-old man was referred to our hospital with hematemesis. Gastroscopy revealed a submucosal-like tumor on the posterior wall of gastric angle with ulceration. Computed tomography indicated a tumor measuring 65 × 50 mm in the stomach, which was suspected to have invaded into the pancreas. Significant hematemesis recurred; the patient developed shock and underwent emergency distal gastrectomy, distal pancreatectomy, and splenectomy. The pathology and the clinical course were compatible with SAM splenic artery rupture causing retroperitoneal hemorrhage that penetrated into the stomach. After that surgery, aneurysm of common hepatic artery ruptured and coil embolization was performed.
Conclusion:
SAM is an important cause of intra-abdominal or retroperitoneal hemorrhage in patients without underlying disease. SAM typically presents as intra-abdominal hemorrhage, but, in this case, the retroperitoneal hemorrhage penetrated into the stomach and it looked like a submucosal tumor.
Insights
Segmental arterial mediolysis (SAM) is a rare arteriopathy causing severe intra-abdominal hemorrhage. This case highlights SAM presenting as a gastric submucosal tumor due to retroperitoneal hemorrhage.
Area of Science:
- Vascular Medicine
- Gastroenterology
- Pathology
Background:
- Segmental arterial mediolysis (SAM) is a rare arteriopathy affecting splanchnic arteries.
- It can lead to aneurysm, dissection, stenosis, or occlusion, causing significant intra-abdominal hemorrhage or bowel ischemia.
- Acute SAM events have a high mortality rate of up to 50%.
Observation:
- A 51-year-old male presented with hematemesis and a gastric submucosal-like tumor.
- Imaging suggested a large stomach tumor potentially invading the pancreas.
- The patient experienced recurrent hematemesis and shock, necessitating emergency surgery.
Findings:
- Pathology confirmed SAM, specifically a splenic artery rupture causing retroperitoneal hemorrhage that penetrated into the stomach.
- Post-surgery, a common hepatic artery aneurysm ruptured, requiring coil embolization.
- The presentation mimicked a gastric submucosal tumor.
Implications:
- SAM is a critical cause of intra-abdominal and retroperitoneal hemorrhage in individuals without predisposing conditions.
- This case demonstrates an unusual presentation of SAM, where retroperitoneal bleeding mimicked a gastric tumor.
- Recognizing atypical SAM presentations is vital for timely diagnosis and management.
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