Case report: Splenic artery pseudoaneurysm mimicking a bleeding marginal ulcer in a patient with gastric bypass

Upper gastrointestinal (GI) bleeding in patients with roux-en-Y gastric bypass can be difficult to localize. Marginal ulcers are the most common cause, but a broad differential should be maintained in cases of severe bleeding, especially since the stomach and duodenum are not easily accessible by regular upper endoscopy.

A 38-year-old female with Roux-en-Y gastric bypass presented with abdominal pain and hematochezia. Due to history of smoking and heavy use of ibuprofen, she was initially thought to have a bleeding marginal ulceration. Further investigation with computed tomographic (CT) angiography revealed a splenic artery pseudoaneurysm that had ruptured into a pancreatic pseudocyst, the gastric remnant and the peritoneum. The patient underwent successful treatment with trans-arterial embolization.

Splenic artery pseudoanerysms are rare but potentially lethal if unrecognized, particularly in patients with altered foregut anatomy. Their most likely origin is a nearby pancreatic pseudocyst, which erodes into the splenic artery by direct pressure and enzymatic digestion. Bleeding inside the pseudocyst is the most feared complication, resulting in massive intraperitoneal, extraperitoneal or endoluminal hemorrhage. Surgery is particularly challenging due to intense peripancreatic inflammation. Trans-Anterial embolization is the preferred treatment modality.

Marginal ulcers continue to be the most common cause of GI bleeding in patients with Roux-en-Y anatomy, although high index of suspicion for alternative diagnosis should be maintained in cases of massive hemorrhage.