Hepatic Artery Pseudoaneurysm Presenting as Gastrointestinal Hemorrhage

Abstract

A hepatic artery pseudoaneurysm (HAP) is a rare complication of laparoscopic cholecystectomy. It can vary in its clinical presentation; however, given its severe nature, prompt assessment and management are crucial. We report a case of a 73-year-old male who underwent a laparoscopic cholecystectomy complicated by a right hepatic artery injury. This subsequently presented as a life-threatening case of upper gastrointestinal bleeding from HAP, with presumable hemobilia and septic shock from multiple liver abscesses. The diagnosis was made with computed tomography angiography (CTA) of the abdomen and pelvis followed by visceral angiography. The patient ultimately underwent a right hepatectomy for definitive treatment. The primary objective of this case is to highlight a less novel, though rare, case presentation and define a spectrum of treatment options available based on severity.

Late Hemorrhage Following Laparoscopic Cholecystectomy

“…2 It can manifest as a delayed complication after an operatively repaired HA injury. 18 In the absence of an obvious HA injury, the possible pathophysiological events leading to formation of PsA after LC, are still unknown but hypothetically it can be because of direct, incomplete injury, to the arterial wall due to dissipating energy from a laser or monopolar electrical energy source. 8,19 Alternately, it could be due to indirect conduction through a clip onto the vessel wall, 2,8,20 although this latter hypothesis, seems less likely considering that clips are the last to be applied, after energy aided dissection in the Calot's triangle is complete.…”

“…40 Although, a much more formidable partial hepatectomies following ischemia have also been reported. 13,18,36 But post-treatment parenchymal vascular compromise, which may need partial hepatectomy, can also be avoided by proper evaluation of the RHA variations 39 and assessment of adequate arterial and collateral blood flow prior to embolization especially in an already compromised liver parenchyma, such as cirrhosis. 8,38 The hemoperitoneum, in our second patient, was because of an unrelated cause, but occurred in the same period, and was much more difficult to diagnose.…”

Atypical Presentation of Left Hepatic Artery Pseudoaneurysm

“…HAPs are mostly asymptomatic and found incidentally in nontraumatic cases. 4 In some cases, the patient can present with hemobilia because of communication with the gallbladder and biliary radicles through an arterobiliary fistula. The Quincke triad is the classic presentation of hemobilia that includes right upper quadrant abdominal pain, jaundice, and upper gastrointestinal bleeding.…”

“…However, patients can also present with the classic Quincke triad (jaundice, biliary colic, and gastrointestinal bleeding). 4 We report a case of HAP secondary to a pyogenic liver abscess that presented with hemobilia, high-grade fever, upper abdominal pain, and jaundice.…”