Left gastric artery is the largest artery supplying the stomach. It takes origin from celiac trunk as trifurcation with common hepatic and splenic artery. It may have a direct origin from the aorta. [1] This variation is significantly important in angiographic treatment of gastrointestinal hemorrhage. Angiographic embolization of such aberrant vessel is easier than normal anatomical one.

A 56-year-old male was referred from gastrointestinal centre for endoscopic ultrasound (EUS) and fine needle aspiration (FNA) of splenic abscess for evaluation of weight loss. The patient was hemodynamically stable and no evidence of hematemesis or melena.

Endoscopic ultrasound guided FNA was done from splenic abscess along the greater curvature of stomach and no other intervention was done. During observation period, patient had tachycardia and pain abdomen and one episode of hematemesis. Computed tomography (CT) angiography was done which showed intragastric bleeding from left gastric artery. (Figure 1) Endoscopy was repeated and a spurting vessel in lesser curve was found and three endo-clips were applied, bleeding was stopped. In this particular case left gastric artery was arising from aorta directly. (Figure 2) (Figure 3) (Figure 4) Patient was admitted with future plan of endovascular intervention but with no evidence of bleeding after 48 hours he was discharged home.

Computed tomography angiography finding: Left gastric artery was found directly arising from anterior surface of abdominal aorta cranial to hepatolienal trunk. Hepatolienal trunk (Figure 1) was arising from anterior aspect of aorta just caudal to the origin of left gastric artery. (Figure 2) (Figure 3) (Figure 4) Diameter of left gastric artery is 2.9 mm and of hepatolienal trunk was 6.3 mm. High attenuation (50–70 HU) material was seen in the stomach which was suggestive of hemorrhagic content. (Figure 1) In addition, endoclips were seen along lesser curvature of stomach.

The classic description of normal celiac trunk anatomy is that the main trunk trifurcates into the left gastric, splenic and common hepatic arteries, which was found in 86%. [1] Reported cases of left gastric artery origin directly from aorta widely vary from 0.5–5%. [1]

In 1928, Adachi first classified anatomical variations of the coeliac trunk. Adachi and Michels have classified the coeliac trunk into the following six different types: [2] [3]

• Type-1: normal branching
• Type-2: hepatosplenic trunk and left gastric artery from aorta
• Type 3: hepato-spleno-mesentric trunk and left gastric from aorta
• Type-4: hepatogastric trunk and splenic artery from superior mesenteric artery
• Type-5: splenogastric type- splenic and left gastric from the coeliac trunk and common hepatic artery from superior mesenteric artery; and
• Type-6: Celiacomesenteric trunk- splenic, left gastric, common hepatic and superior mesenteric arteries arise from a common trunk.

Variable fusion of right and left primitive yolk arteries when they localize in the dorsalis meso root give rise to these anatomical variations. Probably the hepatogastric trunk originates from right yolk artery, and the splenomesenteric trunk from the left one. [4]

Sound knowledge of anatomical variation of celiac trunk is important for liver transplant surgeon and laparoscopic surgeon. With technical improvement, application of radiological intervention increases in gastroenteric diseases and penetrating abdominal trauma. Radiological anatomy of celiac axis and variation is basic requirement for such intervention. [5]

It is worth mentioning that the reported findings are interesting given that this variation is quite rare and is not responsible for any hemodynamic problems. [6]

There are level I evidences in favor of early endoscopy (within the first 24 hours of an acute upper gastrointestinal bleeding (UGIB) episode) in upper gastrointestinal bleeding. Early endoscopy significantly reduces rates of recurrent bleeding, the need for emergent surgery, and mortality in patients with acute non-variceal upper gastrointestinal bleeding. [7] Early endoscopy is appropriate for most patients and reduces mortality by 50%. [8]

Hemostatic clips and endoclips: Clip immediately closes the defect in the vessel wall and stops the bleeding. Modification of the delivery system has made clip placement much easier. Four models of hemoclips are available: QuickClip, Resolution Clip; TriClip and InScope Clip. Out of all these, Resolution Clip is the clip of choice. Present best evidence shows the efficacy of hemoclips is similar to that of thermal coagulation in regards to control of initial bleeding, rebleeding rates and procedure duration. [9] [10]

endoclips may be preferred over other hemostatic methods in treatment of ulcers with coagulopathy or who require ongoing anticoagulation. Endoclips may also be preferable in the retreatment of lesions that rebleed after initial thermal hemostasis and active bleeding from larger vessel. [10]

Over the Scope Clip Device (OTSC) is a shape-memory nitinol alloy clip. As it is made of nitinol, when the open clip released from the applicator it returns to its initial closed shape and close the defect in the vessel wall. Application is similar to the band ligator device. An endoscopy is performed before application of clip. The OTSC provides a safe alternative to endoclip in management of bleeding. [11]

Bleeding from aberrant artery may be diagnostic problem. Knowledge of anatomical variation and endovascular procedure makes management of such bleeding much easier.

1. Yildirim M, Ozan H, Kutoglu T. Left gastric artery originating directly from the aorta. Surg Radiol Anat 1998;20(4):303–5.   [CrossRef]   [Pubmed]    
2. Adachi B. [Das Arteriensystem der Japaner]. Vol. 2. Verlag der Kaiserlich-Japanischen Universitat zu Kyoto, 1928. Japanese.    
3. Michels NA. Blood supply and anatomy of the upper abdominal organs with descriptive atlas. Philadelphia: Lippincott, 1955.    
4. Mariani GA, Maroni L, Bianchi L, et al. Hepatogastric and splenomesenteric arterial trunks: Anatomical variations report. IJAE 2012;117(2):117.    
5. Munshi IA, Fusco D, Tashjian D, Kirkwood JR, Polga J, Wait RB. Occlusion of an aberrant right hepatic artery, originating from the superior mesenteric artery, secondary to blunt trauma. J Trauma 2000 Feb;48(2):325–6.   [CrossRef]   [Pubmed]    
6. Chitra R. Clinically relevant variations of the coeliac trunk. Singapore Med J 2010 Mar;51(3):216–9.   [Pubmed]    
7. Cooper GS, Chak A, Way LE, Hammar PJ, Harper DL, Rosenthal GE. Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc 1999 Feb;49(2):145–2.   [CrossRef]   [Pubmed]    
8. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010 Jan 19;152(2):101–13.   [CrossRef]   [Pubmed]    
9. Lin HJ, Hsieh YH, Tseng GY, Perng CL, Chang FY, Lee SD. A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding. Am J Gastroenterol 2002 Sep;97(9):2250–4.   [CrossRef]   [Pubmed]    
10. Saltzman JR, Strate LL, Di Sena V, et al. Prospective trial of endoscopic clips versus combination therapy in upper GI bleeding (PROTECCT--UGI bleeding). Am J Gastroenterol 2005 Jul;100(7):1503–8.   [CrossRef]   [Pubmed]    
11. Jayaraman V, Hammerle C, Lo SK, Jamil L, Gupta K. Clinical Application and Outcomes of Over the Scope Clip Device: Initial US Experience in Humans. Diagn Ther Endosc 2013;2013:381873.   [CrossRef]   [Pubmed]