A 50-year-old male patient with a known medical history of diabetes mellitus (DM) and hypertension (HTN), managed irregularly, presented to our hospital in Sana'a City, Yemen, on 25 May 2022, at 5:30 pm. The patient was referred to another hospital and reported severe abdominal pain that lasted for one week before admission. The pain was localized in the epigastric region, of sudden onset, progressively worsening, and radiating to the back. In addition, the patient experienced generalized abdominal distension, nausea, vomiting, and significant fatigue. A history of melena and food-related vomiting was also reported over the past month. Two days before admission, the patient had received a blood transfusion of 2 units. There was no history of previous surgeries or a family history of malignancy.
Upon examination, the patient was conscious and alert but exhibited severe pallor. Blood pressure was recorded as 90/60 mmHg and the pulse rate was 120 beats per minute. Generalized abdominal distension, particularly prominent in the supraumbilical region with downward displacement of the umbilicus, was observed. Mild tenderness was present in the epigastric area, along with positive bowel sounds.
Hematological and biochemical investigations revealed hypochromic microcytic anemia with a hemoglobin level of 6 g/dL (normal range: 12–15.5 g/dL), a white blood cell count of 16,000 (normal range: 4–10,000), and a platelet count of 303. The blood urea nitrogen level was 7 mg/dL (normal range: 10–20 mg/dL), creatinine was 0.49 mg/dL (normal range: 0.7–1.5% / dL), the international normalized ratio was 1.34 (normal range: 0.62–1.3), the prothrombin time (PT) was 16.9, the partial thromboplastin time (PTT) was 30, calcium was 8.0 mg/dL (normal range: 8.5–10.1 mg / dL) and lactic acid was 1.9 mmol/L (normal range: 0.5–2.2% / L). Liver enzymes and amylase levels were within normal limits.
Diagnostic imaging studies were conducted, including erect chest radiograph and abdominal ultrasound. The chest radiograph did not reveal any subdiaphragmatic air, but an elevation was observed in the left diaphragm. Abdominal ultrasound demonstrated the presence of an intraabdominal fluid collection. Subsequently, an abdominal CT angiography was performed (Fig. 1), which revealed a hematoma measuring approximately 14.3x8.8 cm in the paraumbilical region. Within the hematoma, a 3.4x2.2 cm arterial aneurysm connected to the gastroduodenal artery was identified, accompanied by surrounding edematous changes. These findings were suggestive of a large, thrombosed aneurysm in the gastroduodenal artery. Additionally, eventration of the left diaphragm that contains the spleen and part of the stomach was observed, along with mild to moderate intraperitoneal fluid collection. No evidence of an aortic aneurysm was detected.
To stabilize the patient, resuscitation was initiated with 1000 ml of Ringer lactate, and three units of fresh blood were transfused. Informed consent for high-risk intervention was obtained and the patient was immediately taken to the operating room. Under general anesthesia, in the supine position and with strict adherence to aseptic techniques, a midline laparotomy incision was performed. When the peritoneum was opened, approximately 2000 ml of blood was evacuated, revealing an occluded, pulsating mass in the duodenum. Adequate exposure was achieved using a self-reinforcement retractor. The liver flexure and the transverse colon were mobilized inferiorly from the head of the pancreas, and clotted blood was removed from the lesser momentum. Meticulous dissection was performed over the large pulsatile occluded aneurysm in the gastroduodenal artery by opening the gastrohepatic ligament. Mobilization of the pylorus and duodenum away from the head of the pancreas exposed a fistula connecting the duodenum and the aneurysm, devoid of digestive content. Following heparinization, proximal and distal clamping of the gastroduodenal artery was performed. The pseudoaneurysm was subsequently opened and a significant amount of thrombus was evacuated. Aneurysmorrhaphy was performed using proline 7.0 sutures. The perforation in the first part of the duodenum was repaired in two layers and a nasogastric tube (NGT) was inserted beyond the perforation. Thorough irrigation with normal saline and meticulous hemostasis were achieved. An abdominal drain was placed, and the abdominal incision was closed in layers. The patient was then transferred to the intensive care unit (ICU) for close monitoring and observation.
During the postoperative period, the abdominal drain collected approximately 100 ml of serous fluid, which was removed the third day after the operation. The patient's recovery progressed without complications. After ten days after surgery, the patient was discharged home in favorable condition. Follow-up appointments were scheduled in the outpatient department and regular communication was maintained by telephone, with the patient's condition reported as satisfactory.