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Khawjah A, Khair MM, Goubran R. An unusual case of acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction: a case report and review of literature. Ann Med Surg (Lond) 2024; 86:3646-3651. [PMID: 38846883 PMCID: PMC11152821 DOI: 10.1097/ms9.0000000000002038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/28/2024] [Indexed: 06/09/2024] Open
Abstract
Introduction Cystic artery pseudoaneurysm rupture presents a rare yet potentially fatal aetiology for upper gastrointestinal (GI) bleed. While uncommon, its incidence has been rising with increased hepatobiliary surgical interventions, predominantly attributed to iatrogenic injury and rarely secondary to acute cholecystitis. Clinical manifestations typically include epigastric pain, upper GI haemorrhage, and obstructive jaundice. Due to its rarity, it is often excluded from initial differential diagnoses. Case report This is an unusual case of a 54-year-old male who presented with acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction, in the setting of cystic artery pseudoaneurysm rupture. Initially, urgent transcatheter angiographic embolization of the cystic artery was performed to achieve hemodynamic stability. However, a triphasic computed tomography (CT) scan revealed the first attempt was unsuccessful, necessitating a second embolization. Subsequent imaging confirmed satisfactory embolization; however, a small area of liver necrosis was observed adjacent to the gallbladder. The patient was stable at discharge from the hospital and had an uncomplicated interval cholecystectomy. Discussion This case highlights the complexity and challenges associated with diagnosing and managing cystic artery pseudoaneurysm rupture. Diagnosis often relies on arterial phase contrast-enhanced CT scan. While no guideline currently exist, management typically involves achieving hemodynamic stability through Transcatheter angiographic embolization, followed by interval cholecystectomy. Conclusion Early recognition and intervention are crucial in managing cystic artery pseudoaneurysm rupture to prevent life-threatening haemorrhagic shock. Clinicians need to consider this rare condition in patients with upper GI bleeding and abnormal liver function tests.
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Affiliation(s)
- Ahmed Khawjah
- Letterkenny University Hospital, Letterkenny, Co. Donegal
| | | | - R. Goubran
- Galway University Hospital, Co. Galway, Ireland
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Cystic Artery Pseudoaneurysm: Current Review of Aetiology, Presentation, and Management. Surg Res Pract 2021; 2021:4492206. [PMID: 34869829 PMCID: PMC8635945 DOI: 10.1155/2021/4492206] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/28/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background Cystic artery pseudoaneurysms are rare. Most commonly, they occur secondary to acute cholecystitis or after a cholecystectomy. Complications include haemobilia, biliary obstruction, and haemorrhage. Given the rarity and associated morbidity, a high index of suspicion is required. This article reviews the current literature on cystic artery pseudoaneurysms to investigate its aetiology, clinical presentation, and management options. Methods A broad search of the Medline and PubMed databases was carried through. All peer reviewed literatures published in the English language between 1991 and 2020 with keywords "cystic" and "artery" and "pseudoaneurysm" in the title were selected for review. No further exclusion criteria; all studies yielded from the search were included in the results of this review. Additionally, we present a case of cystic artery pseudoaneurysm treated at our centre and included this in our analysis. Results Sixty-seven case reports were found between 1991 and 2020. Aetiologies: Aetiology of cystic artery pseudoaneurysm was found to be cholecystitis in 41 instances (61.2%), cholecystectomy in 18 instances (26.8%), idiopathic in 6 instances (8.9%) cholelithiasis in 1 instance (1.5%), and pancreatitis in 1 instance (1.5%). Complications: Fifty-two cases were complicated by haemobilia (77.6%), 36 by anaemia (53.7%), 25 by biliary obstruction (37.3%), 13 by haemodynamic shock (19.4%), 9 by haemoperitoneum (13.4%), and 6 by contained rupture (8.9%). Most commonly, patients had two or more of these complications. Management: Forty-four patients were managed with endovascular embolisation (65.7%), 21 with endoscopic intervention (31.3%), 18 with open cholecystectomy (26.9%), 13 with laparoscopic cholecystectomy (19.4%), and 6 with pseudoaneurysm ligation (9%). Delayed presentation postcholecystectomy ranged from 8 days to 3 years. Conclusions Cystic artery pseudoaneurysms are rare complications of a common operation. The most common clinical presentation is haemobilia, which can be difficult to diagnose clinically. A high index of suspicion and prompt investigation with targeted imaging and intervention is required. This is especially pertinent in gastrointestinal bleeding postlaparoscopic cholecystectomy as a missed diagnosis could cause significant morbidity.
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Das M, Volmar FH, Walayat S, Nolte R. Hemobilia from a right hepatic artery pseudoaneurysm due to chronic cholecystitis. SAGE Open Med Case Rep 2019; 7:2050313X19872075. [PMID: 31489197 PMCID: PMC6710687 DOI: 10.1177/2050313x19872075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 07/31/2019] [Indexed: 11/22/2022] Open
Abstract
Splanchnic pseudoaneurysms are rare causes of hemobilia. Specifically, hepatic artery pseudoaneurysms from infectious or inflammatory etiology are even more rare. In this article, we describe our encounter with a 72-year-old female presenting with obstructive jaundice and acute blood loss anemia. Upper endoscopy indicated hemobilia and endoscopic retrograde cholangiopancreatography was completed with stent in place. Post endoscopic retrograde cholangiopancreatography, computed tomography angiogram indicated a right hepatic artery pseudoaneurysm which was the cause of her hemobilia. The patient was ultimately treated with selective coil embolization and interval cholecystectomy.
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Affiliation(s)
- Manjusha Das
- Division of Gastroenterology and Hepatology, College of Medicine, University of Illinois, Peoria, IL, USA
| | - Fritz-Henry Volmar
- Division of Gastroenterology and Hepatology, College of Medicine, University of Illinois, Peoria, IL, USA
| | - Saqib Walayat
- Department of Internal Medicine, College of Medicine, University of Illinois, Peoria, IL, USA
| | - Ryan Nolte
- Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center, Peoria, IL, USA
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Fujimoto Y, Tomimaru Y, Hatano H, Noguchi K, Nagase H, Hamabe A, Hirota M, Oshima K, Tanida T, Morita S, Imamura H, Iwazawa T, Akagi K, Dono K. Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:187-193. [PMID: 29459583 PMCID: PMC5829622 DOI: 10.12659/ajcr.907273] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Patient: Male, 90 Final Diagnosis: Ruptured cystic artery pseudoaneurysm Symptoms: Epigastric pain • Fever Medication: — Clinical Procedure: Open cholecystectomy Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Yuji Fujimoto
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Yoshito Tomimaru
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hisanori Hatano
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan.,Department of Surgery, Rinku General Medical Center, Izumisano, Osaka, Japan
| | - Kozo Noguchi
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hirotsugu Nagase
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Atsushi Hamabe
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masashi Hirota
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kazuteru Oshima
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Tsukasa Tanida
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Shunji Morita
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Hiroshi Imamura
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Takashi Iwazawa
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kenzo Akagi
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Keizo Dono
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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5
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Loizides S, Ali A, Newton R, Singh KK. Laparoscopic management of a cystic artery pseudoaneurysm in a patient with calculus cholecystitis. Int J Surg Case Rep 2015; 14:182-5. [PMID: 26291047 PMCID: PMC4573867 DOI: 10.1016/j.ijscr.2015.08.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 08/04/2015] [Indexed: 11/30/2022] Open
Abstract
Pseudoaneurysm of the cystic artery following acute cholecystitis is rare. It can be safely managed laparoscopically with simultaneous cholecystectomy. This avoids multiple invasive procedures and decreases morbidity associated with open surgery. INTRODUCTION Pseudoaneurysm of the cystic artery is very rare. In the majority of cases it has been reported as a post-operative complication of laparoscopic cholecystectomy, however it has also been associated with the presence of acute cholecystitis or pancreatitis. When these pseudoaneurysms rupture they can lead to intraperitoneal bleeding, haemobilia and upper gastrointestinal haemorrhage. Radiological as well as open surgical approaches have been described for control of this rare pathology. PRESENTATION OF CASE We report the laparoscopic surgical management of an incidental, unruptured cystic artery pseudoaneurysm in a patient presenting with acute cholecystitis. DISCUSSION Cystic artery pseudoaneurysm is a rare entity and as such there is no consensus on the clinical management of this condition. A variety of treatment strategies have been reported in the literature including radiological selective embolisation and coiling, open cholecystectomy with ligation of the aneurysm, or a two-step approach involving radiological management of the pseudoaneurysm followed by an elective cholecystectomy. CONCLUSION In this report we have demonstrated that laparoscopic management of a cystic artery pseudoaneurysm with simultaneous laparoscopic cholecystectomy is feasible and safe. This avoids multiple invasive procedures and decreases morbidity associated with open surgery.
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Affiliation(s)
- Sofronis Loizides
- Department of Upper Gastrointestinal Surgery, Ashford and St Peters NHS Trust, UK
| | - Asad Ali
- Department of Upper Gastrointestinal Surgery, Ashford and St Peters NHS Trust, UK.
| | - Richard Newton
- Department of Upper Gastrointestinal Surgery, Ashford and St Peters NHS Trust, UK
| | - Krishna Kumar Singh
- Department of Upper Gastrointestinal Surgery, Worthing Hospital, Western Sussex NHS Trust, Worthing, UK
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6
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Unruptured cystic artery pseudoaneurysm accompanied by Mirizzi syndrome: a report of a case. Clin J Gastroenterol 2013; 6:490-5. [DOI: 10.1007/s12328-013-0434-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 10/11/2013] [Indexed: 10/26/2022]
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7
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Senadhi V, Arora D, Arora M, Dutta S. Hemobilia caused by a ruptured hepatic cyst: a case report. J Med Case Rep 2011; 5:26. [PMID: 21251320 PMCID: PMC3038954 DOI: 10.1186/1752-1947-5-26] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Accepted: 01/20/2011] [Indexed: 11/22/2022] Open
Abstract
Introduction Hemobilia is a rare cause of upper gastrointestinal bleeding. More than 50% of hemobilia cases are related to iatrogenic trauma from hepatobiliary procedures, and needle biopsy of the liver represents the most common cause. A minority of hemobilia cases are due to hepatobiliary disorders such as cholangitis, hepatobiliary cancers, choledocholithiasis, and vascular abnormalities in the liver. The classic presentation of hemobilia is the triad of right upper quadrant (biliary) pain, obstructive jaundice, and upper gastrointestinal bleeding. We report a rare case of hemobilia caused by a spontaneous hepatic cyst rupture, where our patient presented without the classical symptoms, in the absence of therapeutic or pathological coagulopathy, and in the absence of spontaneous or iatrogenic trauma. Case presentation A 91-year-old African-American woman was referred to our out-patient gastroenterology clinic for evaluation of mild epigastric pain and intermittent melena. An abdominal computed tomography scan was remarkable for multiple hepatic cysts. Esophagogastroduodenoscopy revealed multiple blood clots at the ampulla of Vater. Endoscopic retrograde cholangiopancreatography showed a single 18 mm-sized filling defect in the common hepatic duct wall at the junction of the right and left hepatic duct, adjacent to one of the hepatic cysts. The ruptured hepatic cyst communicated to the bile ducts and was the cause of hemobilia with an atypical clinical presentation. Conclusion Hemobilia is an infrequent cause of upper gastrointestinal bleeding and rarely occurs due to hepatic cyst rupture. To the best of our knowledge, this is only the second case report in the literature that describes hemobilia due to hepatic cyst rupture. However, it is the first case in the literature of hemobilia due to hepatic cyst rupture in the absence of iatrogenic or spontaneous trauma, and in the absence of a spontaneous or pathological coagulopathy.
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Affiliation(s)
- Viplove Senadhi
- Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Sinai Hospital, Baltimore, MD, USA.
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8
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Abstract
Hemobilia is an uncommon medical problem that presents in a varied fashion and is increasingly of iatrogenic origin. The diagnosis of hemobilia needs to be considered in patients presenting with upper gastrointestinal bleeding, particularly if they are jaundiced with abdominal pain in the setting of recent or previous percutaneous liver intervention or abdominal trauma. Multislice computed tomographic angiography is increasingly being used in the investigation, but transcatheter arterial embolization remains the cornerstone of managing those patients requiring intervention. The majority of patients with hemobilia will be managed supportively or with radiologic intervention; most do not require surgical intervention.
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Affiliation(s)
- Marcus W Chin
- University of Western Australia, St Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada.
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9
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Hague J, Brennand D, Raja J, Amin Z. Cystic Artery Pseudoaneurysms in Hemorrhagic Acute Cholecystitis. Cardiovasc Intervent Radiol 2010; 33:1287-90. [DOI: 10.1007/s00270-010-9861-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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Microcoil Embolisation of Mycotic Cystic Artery Pseudoaneurysm: A Viable Option in High-Risk Patients. Cardiovasc Intervent Radiol 2009; 32:1275-9. [PMID: 19449062 DOI: 10.1007/s00270-009-9590-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 04/03/2009] [Accepted: 04/07/2009] [Indexed: 01/04/2023]
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Machida H, Ueno E, Shiozawa S, Fujimura M, Tsuchiya A, Kim DH, Ogawa K, Aiba M. Unruptured pseudoaneurysm of the cystic artery with acute calculous cholecystitis incidentally detected by computed tomography. ACTA ACUST UNITED AC 2008; 26:384-7. [DOI: 10.1007/s11604-008-0243-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Accepted: 03/17/2008] [Indexed: 11/30/2022]
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Abstract
The increased use of interventional procedures and laparoscopic cholecystectomy in the management of hepatobiliary disorders is associated with an increased incidence of hemobilia and hepatic artery aneurysm. Here we report a case of hepatic artery pseudoaneurysm associated with a plastic biliary stent. Multiple factors were involved in the formation of the hepatic artery aneurysm (HAA) and it was successfully treated by embolization.
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Affiliation(s)
- Jeong Youp Park
- Division of Gastroenterology, Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 250 Seongsanno, Seodaemoon-gu, Seoul 120-752, Korea
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13
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Spahn TW, Ullerich HJ, Lebitz P, Wormanns D, Gaubitz M, Mueller MK, Domschke W. Gastrointestinal bleeding secondary to hepatic artery involvement of microscopic polyangiitis: case report and review of the literature. Dig Dis Sci 2007; 52:1558-61. [PMID: 17410468 DOI: 10.1007/s10620-006-9267-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Accepted: 02/13/2006] [Indexed: 12/31/2022]
Affiliation(s)
- Thomas W Spahn
- Department of Medicine B, Muenster University Hospital, Muenster, Germany.
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14
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Akatsu T, Tanabe M, Shimizu T, Handa K, Kawachi S, Aiura K, Ueda M, Shimazu M, Kitajima M. Pseudoaneurysm of the cystic artery secondary to cholecystitis as a cause of hemobilia: report of a case. Surg Today 2007; 37:412-7. [PMID: 17468824 DOI: 10.1007/s00595-006-3423-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 12/04/2006] [Indexed: 02/07/2023]
Abstract
Spontaneous intracholecystic bleeding is very rare. We report herein a very rare case of a pseudoaneurysm of the cystic artery due to acute cholecystitis. A 58-year-old man presented at the emergency department complaining of colicky pain in the right upper quadrant. Dynamic magnetic resonance imaging demonstrated an early-enhanced pooling of contrast material (suggestive of a pseudoaneurysm of the cystic artery) inside the neck of the gallbladder. After the proximal control of the hepatic artery, the patient underwent a cholecystectomy and a ligation of the cystic artery. The resected specimen of the gallbladder showed evidence of a massive intracholecystic hematoma. Proximal to the impacted gallstone in the neck, a 2-cm diameter saccular-type pseudoaneurysm was identified. Although a pseudoaneurysm of the cystic artery is very rare, it should be included in the differential diagnosis of hemobilia. Once the pseudoaneurysm is confirmed, its embolization before a cholecystectomy (which can be attempted laparoscopically) may be useful to ensure the safety of the patient.
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Affiliation(s)
- Tomotaka Akatsu
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
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15
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Saluja SS, Ray S, Gulati MS, Pal S, Sahni P, Chattopadhyay TK. Acute cholecystitis with massive upper gastrointestinal bleed: a case report and review of the literature. BMC Gastroenterol 2007; 7:12. [PMID: 17386110 PMCID: PMC1851966 DOI: 10.1186/1471-230x-7-12] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Accepted: 03/26/2007] [Indexed: 01/04/2023] Open
Abstract
Background Cystic artery pseudoaneurysm is a rare complication following cholecystitis. Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer. Thirteen patients with cystic artery pseudoaneurysm have been reported in the literature but only 2 of them presented with UGIH alone. Case presentation We report a 43-year-old woman who developed a cystic artery pseudoaneurysm following an episode of acute cholecystitis. She presented with haematemesis and melaena associated with postural symptoms. Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum. Ultrasonography detected gallstones and a pseudoaneurysm at the porta hepatis. Selective hepatic angiography showed two small pseudoaneurysms in relation to the cystic artery, which were selectively embolized. However, the patient developed abdominal signs suggestive of gangrene of the gall bladder and underwent an emergency laparotomy. Cholecystectomy with common bile duct exploration along with repair of the duodenal rent, and pyloric exclusion and gastrojejunostomy was done. Conclusion This case illustrates the occurrence of a rare complication (pseudoaneurysm) following cholecystitis with an unusual presentation (UGIH). Cholecystectomy, ligation of the pseudoaneurysm and repair of the intestinal communication is an effective modality of treatment.
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Affiliation(s)
- Sundeep S Saluja
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Sukanta Ray
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Manpreet S Gulati
- Department of Radiology Ground floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Sujoy Pal
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Peush Sahni
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
| | - Tushar K Chattopadhyay
- Department of Gastrointestinal surgery, Room No 1005, PC block, 1floor, AIIMS, Ansari Nagar, New Delhi, 110029, India
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Abstract
BACKGROUND The formation of a pseudoaneurysm of the cystic artery is a rare occurrence after laparoscopic cholecystectomy. CASE OUTLINE Seven weeks after laparoscopic cholecystectomy, a 31-year-old woman presented with a picture of obstructive jaundice. The diagnosis of cystic artery aneurysm was verified by arteriography, CT and MRCP. At laparotomy the pseudoaneurysm was found to be compressing the common bile duct. It was successfully managed by ligation of the right hepatic artery. DISCUSSION Although this complication is rare, the surgeon must have a high index of suspicion to make the diagnosis.
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Affiliation(s)
- O. L. De Molla Neto
- Department of Liver Transplant and Surgery, Hospital Santa PaulaSão PauloBrazil
| | - M. A. F. Ribeiro
- Department of Liver Transplant and Surgery, Hospital Santa PaulaSão PauloBrazil
| | - W. A. Saad
- Department of Liver Transplant and Surgery, Hospital Santa PaulaSão PauloBrazil
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17
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Abstract
Arterio-biliary fistula is an uncommon cause of haemobilia. We describe a case of right hepatic artery pseudo-aneurysm causing arterio-biliary fistula and presenting as severe melaena and cholangitis. Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolization of the pseudo-aneurysm successfully controlled the bleeding. Pseudo-aneurysm of the hepatic artery is mostly iatrogenic due to biliary intervention, as demonstrated in this case. Difficulty in diagnosis and management is discussed together with a review of the literature.
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Affiliation(s)
- Rakesh Rai
- HPB Surgery and Liver Transplant Unit, and Department of Interventional Radiology, Freeman Hospital, Newcastle, UK.
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18
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Abstract
AIM: To highlight the fatal complication caused by expanding biliary stents and the importance of avoiding use of expanding stent in potentially curable diseases.
METHODS: Arteriobiliary fistula is an uncommon cause of haemobilia. We describe a case of right hepatic artery pseudoaneurysm causing arteriobiliary fistula and presenting as severe malena and cholangitis, in a patient with a mesh metal biliary stent. The patient had lymphoma causing bile duct obstruction.
RESULTS: Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolisation of the pseudo aneurysm successfully controlled the bleeding.
CONCLUSION: Bleeding from the pseudo aneurysm of the hepatic artery can be fatal. Mesh metal stents in biliary tree can cause this complication as demonstrated in this case. So mesh metal stent insertion should be avoided in potentially benign or in curable conditions. Difficulty in diagnosis and management is discussed along with the review of the literature.
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Affiliation(s)
- Rakesh Rai
- Hepatobiliary Surgery and Liver Transplant Unit, Freeman Hospital, Newcastle, UK.
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19
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Abstract
BACKGROUND The aim was to evaluate a non-operative approach to the management of haemobilia. METHODS This was a retrospective analysis of patients presenting over 10 years with haemobilia. All patients had upper gastrointestinal endoscopy, abdominal ultrasonography and digital subtraction angiography. Superselective coil and/or Gelfoam embolization was done as close as possible to the bleeding site. Completion angiography was performed routinely to confirm adequate embolization. RESULTS There were 23 patients with liver trauma and six with inflammatory conditions. All patients required resuscitation with fluids and blood transfusion, and had the haemobilia controlled successfully by angiographic embolization. There was one death from fulminant hepatic sepsis. CONCLUSION This series attests to the efficacy of a non-operative approach to haemobilia using radiological diagnosis and intervention.
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Affiliation(s)
- J Moodley
- Department of General Surgery, University of Natal, Durban, South Africa.
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20
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Abstract
Aneurysms are a rare cause of hemobilia, and usually involved are branches of the hepatic and gastro-duodenal arteries. A case of a patient with hemobilia secondary to a pseudoaneurysm of the cystic artery is presented. Fewer than 10 cases have been reported in the literature, and in all of them the condition was associated with inflammation of the gall bladder, as in our case. Selective hepatic angiography is the procedure of choice for diagnosis. Upper gastrointestinal endoscopy with side-viewing scopy can demonstrate bleeding from papilla. Color-Doppler ultrasonography also may prove to be useful in equivocal cases. Cholecystectomy and ligation of cystic artery with proximal control of the hepatic artery was done at laparotomy after diagnosis was made.
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Affiliation(s)
- L Kaman
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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21
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Ribeiro A, Williams H, May G, Fulmer JT, Spivey JR. Hemobilia due to hepatic artery pseudoaneurysm thirteen months after laparoscopic cholecystectomy. J Clin Gastroenterol 1998; 26:50-3. [PMID: 9492864 DOI: 10.1097/00004836-199801000-00013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although vascular complications following laparoscopic cholecystectomy are rare, hemobilia may occur within the first 4 weeks after surgery. We report a 57-year-old woman with hemobilia secondary to a pseudoaneurysm of the right hepatic artery presenting 13 months after laparoscopic cholecystectomy. To our knowledge, such late presentation has never before been reported.
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Affiliation(s)
- A Ribeiro
- Department of Gastroenterology, Mayo Clinic Jacksonville, FL 32224, USA
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22
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Nakajima M, Hoshino H, Hayashi E, Nagano K, Nishimura D, Katada N, Sano H, Okamoto K, Kato K. Pseudoaneurysm of the cystic artery associated with upper gastrointestinal bleeding. J Gastroenterol 1996; 31:750-4. [PMID: 8887048 DOI: 10.1007/bf02347630] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pseudoaneurysm of the cystic artery is a cause of hemobilia, and is extremely rare, with only eight cases having been reported in the world literature. We report a case of pseudoaneurysm of the cystic artery in a 72-year-old Japanese man. The patient experienced epigastric pain and melena, and was found to have jaundice and liver dysfunction. Repeated gastroendoscopy did not reveal the cause of the alimentary tract bleeding; however, color-Doppler ultrasonography detected an aneurysm of the cystic artery in the gallbladder. Selective hepatic arteriography demonstrated that the posterior branch of the cystic artery was markedly dilated and that an aneurysm had formed in the midst of the artery. We diagnosed hemobilia due to the pseudoaneurysm of the cystic artery, and associated gastrointestinal bleeding. Cholecystectomy was performed immediately. Pathologically, the gallbladder showed acute calculous cholecystitis. This case emphasizes the importance of including hemobilia in the differential diagnosis whenever gastrointestinal bleeding is associated with signs of biliary disorder; color-Doppler imaging is a favorable modality for the diagnosis of pseudoaneurysm of the cystic artery.
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Affiliation(s)
- M Nakajima
- Department of Internal Medicine, Koseiren Kamo Hospital, Aichi, Japan
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Cappell MS, Marks M, Kirschenbaum H. Massive hemobilia and acalculous cholecystitis due to benign gallbladder polyp. Dig Dis Sci 1993; 38:1156-1161. [PMID: 8508713 DOI: 10.1007/bf01295736] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A 37-year-old male with metachromatic leukodystrophy, a congenital cerebroside storage disease strongly associated with benign gallbladder polyps, presented with hemobilia and acalculous cholecystitis due to a long, slender, benign gallbladder polyp. This case report extends the clinical spectrum of gallbladder polyps and demonstrates a novel cause of hemobilia. The unusually long, slender polyp shape may have promoted hemorrhage due to the potential for torsion around a slender stalk. The mechanism of cholecystitis may have been cystic duct obstruction from blood clots or possibly from prolapse by the long, slender polyp into the cystic duct.
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Affiliation(s)
- M S Cappell
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick 08903-0019
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24
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Shramek JK, Cooper SG, Wickremesinghe PC. Massive hemobilia resulting from gallstone erosion of the cystic artery: percutaneous transcatheter embolization as a temporizing measure--case report. J Vasc Interv Radiol 1993; 4:373-5. [PMID: 8513210 DOI: 10.1016/s1051-0443(93)71880-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- J K Shramek
- Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital, NY 14642
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