Description

A 56-year-old man was referred to our clinic to investigate the chronic diarrhoea and weight loss. He was healthy until 3 months before admission. He gradually developed chronic small bowel-type diarrhoea. He was a retired man with no history of illness in the past. He never smoked. On physical examination, he was ill and wasted. There were pallor and a brown-pigmented, 5×3 cm skin plaque over the left clavicle. The chest, abdomen, extremities and nervous system were all normal on examination. He had mild anaemia with haemoglobin: 10.8 g/dl. Tests of body iron stores were normal. Therefore, anaemia was not due to iron deficiency. He underwent upper intestinal endoscopy. Biopsy of duodenum showed normal mucosa and no evidence of absorptive disorders. Total colonoscopy demonstrated three pedunculated polyps in descending colon. Histological study showed low-grade dysplasia in excised polyps. CT scan of abdomen showed thickened jejounal loops and a large splenic vein aneurysm (figure 1). He then underwent double-balloon enteroscopy. Biopsy showed no sign of infiltrative or malignant disease of bowels. CT angiography of abdominal vessels showed splenic vein and artery aneurysm near the hilum (figure 2A,B). An arterio-venous fistula was possible. Digital subtraction angiography was necessary to exclude the mentioned connection, but he refused to undergo further imaging. The huge splenic vein aneurysm and the backward flow into the superior mesenteric vein impeded the venous drainage of the small bowel. The congested bowel was probable cause of his diarrhoea. Venous system aneurysms including splenic vein are uncommon. Superior mesenteric vein aneurysm is the most common. It usually occurs in patients with portal hypertension. However, its formation does not need portal hypertension. There are a few reports of splenic vein aneurysm, especially in the puerperium. The venous aneurysms are usually asymptomatic. However, there is risk of aneurismal rupture, thrombosis, or local compressive effects. Therefore, surgery remains the treatment modality of choice for symptomatic patients; otherwise, radiologic survey and follow up are recommended.1,–,4 We did not perform surgery in the patient because he had no intra-abdominal haemorrhage or abdominal vein thrombosis and biopsy of the skin plaque showed the metastasis of an undifferentiated carcinoma. He was referred to the oncologist.

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Figure 1

Section of contrast-enhanced abdominal computed tomography scan demonstrating a large 125×65 mm aneurysm (arrows) in distal portion of splenic vein near the spleen.

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Figure 2

(A, B) Sections of multi-slice spiral contrast-enhanced angiography of abdominal aorta illustrating the same venous aneurysm and a small splenic artery aneurysm (arrows) near the hilum. A suspicious arterio venous connection (arrowhead) is noted between arterial and venous system.