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CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 53-55

Massive hemobilia in a case of hepatic artery pseudoaneurysm: A rare complication after open cholecystectomy


Department of General Surgery, IPGMER and SSKM Hospital, Kolkata, West Bengal, India

Date of Web Publication1-Feb-2016

Correspondence Address:
Bappaditya Har
Room No 230, New PG Hostel, SGPGIMS, Rae Bareilly Road, Lucknow, Uttar Pradesh - 226 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.175209

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  Abstract 


Background: Hepatic arterial pseudoaneurysm with hemobilia occurs less frequently as a complication of open cholecystectomy than laparoscopic cholecystectomy; however, given its severe nature, it needs to be managed promptly. Patient should be evaluated with high index of suspicion, presenting with post cholecystectomy pain with jaundice. They should be treated with angiographic coil embolization of hepatic arteries as a first line management, which is successful in the majority of bleedings: in a minority of cases, even a laparotomy is needed. However, proper use of electrocautery may decrease the occurane of psedoaneurysm. Case Presentation: Here we present a case history of a 50 years old female presenting with massive hematochezia & jaundice with hemodynamic instability, 3 months following open cholecystectomy due to leaking pseudoanurysm from right hepatic artert & treated successfully with angiographic coil embolisation.

Keywords: Angioembolisation, hemobilia, hepatic artery, pseudoaneurysm


How to cite this article:
Har B, Sanfui S, Saha D, Chattopadhyay BK. Massive hemobilia in a case of hepatic artery pseudoaneurysm: A rare complication after open cholecystectomy. Saudi Surg J 2015;3:53-5

How to cite this URL:
Har B, Sanfui S, Saha D, Chattopadhyay BK. Massive hemobilia in a case of hepatic artery pseudoaneurysm: A rare complication after open cholecystectomy. Saudi Surg J [serial online] 2015 [cited 2022 Dec 3];3:53-5. Available from: https://www.saudisurgj.org/text.asp?2015/3/2/53/175209




  Introduction Top


Hemobilia is defined as hemorrhage into the biliary tract.[1] Nowadays iatroginic cause has become thec most common cause of hemobilia. Common bile duct stone, cholecystitis, gallbladder cancer, hepatic artery pseudoaneurysm (HAPA), parasitic infestation, and liver abscess can also cause hemobilia.[1],[2],[3],[4],[5],[6],[7],[8] Rupture/leak of a HAPA into the hepatobiliary tract is a rare cause of hemobilia after open cholecystectomy.[7],[9] Quincke's described first the classic triad of pseudoaneurysm of hepatic artery - upper abdominal pain, obstructive jaundice and hemobilia that is present only in one-third of the patient. Here, we present a case of acute episodes of severe hemobilia with hematochezia following open cholecystectomy in a 50-year-old female, due to ruptured HAPA, and she is treated successfully with emergency angiographic coil embolization.


  Case Report Top


A 50 year old female was referred to us due to several episodes of massive hematochezia with right upper abdominal pain. She underwent open cholecystectomy 3 months back with uneventful recovery. On admission, the patient was conscious, had hypotension (86/60 mmHg), tachycardia, and jaundice. Initial laboratory values are mentioned in [Table 1]. After stabilization, an urgent ultrasonography (USG) with Doppler was done, and it showed a well-defined cystic lesion related gallbladder fossa extending up to porta with color filling-in with arterial pulsation on Doppler [Figure 1] and dilated intrahepatic biliary radical. The patient was managed in the meantime with adequate blood component transfusion and fluid resuscitation. Contrast-enhanced computed tomography (CECT) (triphasic) showed a 5 cm × 5.8 cm × 6 cm hypodense area with delayed enhancement, suggesting a hematoma. There is also a 1.8 cm × 1.2 cm pseudoaneurysm arising from the right branch of hepatic artery adjacent to the hematoma [Figure 2]. An urgent transfemoral angiography was planned, and the aneurysm was seen arising from the right branch of hepatic artery and hematoma sac was found to be feeding from the aneurysm [Figure 3]. The right hepatic artery pseudoaneurysm was successfully embolized using coils both proximally and distally, and post embolization angiographic film showed adequate embolization with no fill-in and adequate collateral in both lobes of the liver [Figure 4].
Table 1: Laboratory values on admission

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Figure 1: Ultrasonography color Doppler showing well-defined cystic lesion in gall bladder fossa with color fill-in with arterial pulsation

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Figure 2: (a) Contrast-enhanced computed tomography (axial) showing a cystic swelling (hematoma) with delayed contrast enhancement and the pseudoaneurysm of right hepatic artery (b) contrast-enhanced computed tomography (coronal) showing a cystic swelling (hematoma) with delayed contrast enhancement and the pseudoaneurysm of right hepatic artery

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Figure 3: Angiography showing aneurysm arising from the right hepatic artery with a hematoma filling from the aneurysm

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Figure 4: Angiography showing aneurysm arising from the right hepatic artery after coil embolization both proximally and distally without fill-in

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  Discussion Top


HAPAs are uncommon, but potentially lethal. The right hepatic artery is the most common artery involved.[9] The first case of hepatic artery aneurysm was described in 1819.[10] The main causes of HAPA were atherosclerosis, medio intimal degeneration, and trauma.[10],[11] HAPA is now caused most commonly by trauma, mainly iatrogenic. Hepatic, biliary, or pancreatic procedures (e.g., liver biopsy, cholecystectomy, hepatectomy, and biliary transhepatic drainage) can cause HAPA.[9] Although HAA may present with epigastric or subcostal pain,[11] the most common presentation of HAPA is bleeding that may present with rupture, several months to years after undergoing any of these procedures.[9] Inadvertent use of electrocautery during operation may cause injury to the vessel wall which later on may form a pseudoaneurysm. During laparoscopic also inexperienced use of electrocautery may injure the vessel wall by direct or capacitive coupling. Although USG with Doppler may suggest the diagnosis of pseudoaneurysm (suggestive with a color fill-in), it may not be present always and it should always be differentiated from local collection/abscess/cyst before any percutaneous intervention. CECT (triphasic) is a very reliable tool confirming the pseudoaneurysm, but angiography is diagnostic. Angiography has also the benefit of performing therapeutic maneuver such as coil embolization which is safe, less morbid, and high success rate. A repeat embolization must be considered before laparotomy and surgery should be considered as a last resort.[9] Furthermore, proper use of electrocautery may decrease the incidence of pseudoaneurysm and associated complications.

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bloechle C, Izbicki JR, Rashed MY, el-Sefi T, Hosch SB, Knoefel WT, et al. Hemobilia: Presentation, diagnosis, and management. Am J Gastroenterol 1994;89:1537-40.  Back to cited text no. 1
    
2.
Goodwin SC, Stainken BF, McNamara TO, Yoon HC. Prevention of significant hemobilia during placement of transhepatic biliary drainage catheters: Technique modification and initial results. J Vasc Interv Radiol 1995;6:229-32.  Back to cited text no. 2
    
3.
Savader SJ, Trerotola SO, Merine DS, Venbrux AC, Osterman FA. Hemobilia after percutaneous transhepatic biliary drainage: Treatment with transcatheter embolotherapy. J Vasc Interv Radiol 1992;3:345-52.  Back to cited text no. 3
    
4.
Yelle JD, Fairfull-Smith R, Rasuli P, Lorimer JW. Hemobilia complicating elective laparoscopic cholecystectomy: A case report. Can J Surg 1996;39:240-2.  Back to cited text no. 4
    
5.
Willemsen PJ, Vanderveken ML, De Caluwe DO, Tielliu IF. Hemobilia: A rare complication of cholecystitis and cholecystolithiasis. Case report. Acta Chir Belg 1996;96:93-4.  Back to cited text no. 5
    
6.
Osawa H, Mori Y, Inoue F. Case report: Malignant haemobilia detected in the gallbladder – Retrograde cholangiographic findings. Br J Radiol 1996;69:79-81.  Back to cited text no. 6
    
7.
Liou TC, Ling CC, Pang KK. Liver abscess concomitant with hemobilia due to rupture of hepatic artery aneurysm: A case report. Hepatogastroenterology 1996;43:241-4.  Back to cited text no. 7
    
8.
Awasthy N, Juneja M, Talukdar B, Puri AS. Hemobilia complicating a liver abcess. J Trop Pediatr 2007;53:278-9.  Back to cited text no. 8
    
9.
Tessier DJ, Fowl RJ, Stone WM, McKusick MA, Abbas MA, Sarr MG, et al. Iatrogenic hepatic artery pseudoaneurysms: An uncommon complication after hepatic, biliary, and pancreatic procedures. Ann Vasc Surg 2003;17:663-9.  Back to cited text no. 9
    
10.
Baggio E, Migliara B, Lipari G, Landoni L. Treatment of six hepatic artery aneurysms. Ann Vasc Surg 2004;18:93-9.  Back to cited text no. 10
    
11.
Abbas MA, Fowl RJ, Stone WM, Panneton JM, Oldenburg WA, Bower TC, et al. Hepatic artery aneurysm: Factors that predict complications. J Vasc Surg 2003;38:41-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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