Aneurysm of the hepatic artery

A housewife, fifty-two years oId, was brought to Freedmen’s Hospital on December 8, 1940, in severe collapse. Her daughter related that about one month earIier the patient had complained of severe abdomina1 pain, following a heavy meal and that for a few days thereafter tarry stooIs were passed. Four days prior to admission she suffered a second attack, foIIowing a heavy meal, which was characterized by persistent epigastric pain, hematemesis, later meIena and eventuaIIy “shock.” The patient was of normal development, we11 nourished and presented the following salient findings: restlessness in spite of evidences of severe collapse; bIood pressure 60/40; icteric scIera; paIe mucous membranes; natura1 but rapid and somewhat faint heart sounds; natural Iung fieIds; soft abdomen, though tender above the umbiIicus; Iiver, spIeen or abnorma1 masses not paIpabIe. The erythrocyte count was 1,940,000; hemogIobin 42 per cent; Ieucocyte count 16,780. The urine was not examined: the patient did not void whiIe in the hospita1 and she was not catheterized. Because of the history and clinica evidences of hemorrhage, immediately after admission the patient was given by vein 300 cc. of whoIe bIood foIIowed by 3,500 cc. of 5 per cent gIucose in normal saIt soIution. ShortIy thereafter, the patient had a severe hematemesis amounting to about 450 cc. In spite of the administration of additiona fluids, the patient faiIed to improve and expired at I I zoo A.M., December 9, 1940, sIightIy over fourteen hours after admission. The significant external findings two hours after death were paIIor and uncIotted bIood in the ora cavity and rectum. There was no free fluid in the abdomina1 cavity, but the stomach, cecum and ascending coIon were distended with cIotted and unclotted blood, amounting to 1,365 cc. in ,the stomach and 950 cc. in the proxima1 colon. In the duodenum, 3.5 cm. from the pyIoric sphincter, there was a bIeeding uIcer 5 by 7 mm. in size and within 1.5 cm. distaIIy there were two nonbleeding uIcers 3 and 4 mm. in diameter. These uIcers occupied a dark purple and softened ova1 area 3 by 5 cm. in diameter, Iocated about the center of a sweIIing 4.5 by 9 cm. in size, invoIving most of the posterior waI1 of the first and second parts of the duodenum, These Iesions were in reIation to a large, partiaIIy hemorrhagic and firm mass, with foci of softening, found behind the duodenum and extending in the gastrohepatic Iigament from the pancreas to the hilum of the liver. The Liver was normaI, but the gaIIbIadder was compressed sIightIy on the media1 side; the extrahepatic bile ducts and the porta vein were displaced backward and sIightIy to the right and were compressed; the foramen of WinsIow was obIiterated; the head of the pancreas was the seat of hemorrhage and the duodena1 wall was necrotic in relation to parts of the hematoma. This mass had resuIted from an aneurysma1 dilatation of the hepatic artery 2 cm. from its origin and a perforation in reIation to the head of the pancreas and duodenum, producing a hematoma. The preserved parts of the intima within the aneurysm showed wrinkIing together with calcification in areas of atherosclerosis. The waIIs had a Iobulated contour; the lumen was fiIIed with a Iaminated thrombus. (Fig. I.) The Ieft branch of the hapatic artery was found coursing upward to the Iiver from the superior surface of the aneurysm at a point about 4.5 cm. from the Iatter’s proxima1 end. The right branch was traced from the liver to the superior surface of the aneurysm, about 1.5 cm. to the right of the origin of the Ieft branch, but no opening into the aneurysm was found at this site. The circuIatory system showed in addition to the lesions of the hepatic artery, moderate hypertrophy of the Ieft ventricIe of the heart * From the Department of Pathology, CoIIege of Medicine, Howard University, Washington, D. C.