Pseudoaneurysm of the Cystic Artery Secondary to Cholecystitis as a Cause of Hemobilia: Report of a Case

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.

Cystic Artery Pseudoaneurysm: Over Warfarinisation and Management

“…Iatrogenic or traumatic liver injury accounts for approximately half of all cases of haemobilia [5]. However, major haemobilia is more commonly associated with sepsis and inflammation producing a pseudoaneursym of the hepatic artery [5].…”

“…However, major haemobilia is more commonly associated with sepsis and inflammation producing a pseudoaneursym of the hepatic artery [5]. Typical features of a haemobilia include RUQ abdominal pain, obstructive jaundice, gastrointestinal haemorrhaging/ melena (Quincke's triad) [1,6].…”

“…Although the detailed mechanism by which acute cholecystitis may lead to a pseudoaneurysm formation is not known, it is thought that with the inflammatory process, a partial erosion of the serosa, elastic and muscular components of the arterial wall contributes to the pseudoaneurysm of the cystic artery [5]. Visceral inflammation adjacent to the arterial wall damages the adventitia and causes thrombosis of the vaso-vasorum resulting in a localised weakness in the vessel wall [1,5].…”

“…Visceral inflammation adjacent to the arterial wall damages the adventitia and causes thrombosis of the vaso-vasorum resulting in a localised weakness in the vessel wall [1,5]. In addition to acute inflammation, severe damage to the GB wall by a large gallstone eroding into the cystic artery can accelerate the formation of a pseudoaneurysm [7].…”

“…The proximal control of the hepatic artery (i.e. encirclement of the proximal hepatic artery in preparation for temporal vascular clamping) may be mandatory in order to avoid serious and uncontrollable bleeding [5]. Serious bleeding can be precipitated, when dissection is performed in an area where there is evidence of acute inflammation containing a pseudoaneurysm [7].…”