Hepatic artery aneurysm, an unusual cause of obstructive jaundice: MR cholangiography findings

Management of a Fulminant Upper Gastrointestinal Bleeding Exteriorized Through Hemobilia Due to Arteriobiliary Fistula Between the Common Bile Duct and a Right Hepatic Artery Aneurysm - A Case Report

Right hepatic artery aneurysms are rare events that might remain asymptomatic for a long period of time. However, in cases presenting large lesions, symptoms might develop especially due to the association of compression of the surrounding elements. Most often these symptoms and signs include diffuse abdominal pain, jaundice or portal vein compression signs. In rare cases life-threatening complications might develop due to the aneurysmal erosion of the biliary duct, portal vein or due to the aneurysmal rupture in the peritoneal cavity. In all these cases emergency surgery is imposed. We present the case of a 66-year-old patient diagnosed with a partially thrombosed right hepatic artery aneurysm compressing the common bile duct who was initially submitted to a percutaneous arterial embolization of the aneurysm in association with an external biliary drainage; three weeks later the patient presented a fulminant upper gastrointestinal bleeding exteriorized through the external biliary drainage, hematemesis and hematochezia. The patient was successfully submitted to surgery, intraoperatively a synchronous rupture of the portal vein being revealed. The right hepatic artery aneurysm was resected en bloc with common bile duct resection and segmental portal vein resection. The continuity of the portal vein was re-established through the interposition of a cadaveric allograft, the common bile duct was anastomosed with en Roux en Y limb while the right hepatic artery aneurysm was ligated and resected, the arterial vascularization of the liver being provided by the left hepatic artery.

Pseudoaneurysm of the gastroduodenal artery: an unusual cause for hyperamylasaemia

A 79-year-old man was admitted electively for investigation of weight loss. While he was an inpatient, he developed severe epigastric pain and an initial blood test revealed an acutely raised amylase (>2000) and deranged liver function tests. A contrast CT angiography showed a large haematoma adjacent to the duodenum, spreading in the retroperitoneal space, arising from a 2 cm bleeding pseudoaneurysm in the region of the gastroduodenal artery. Due to his underlying comorbidities, he was deemed unfit for surgical repair and he had coil embolisation with successful haemostasis. The gastroduodenal artery aneurysms are rare and constitute 1.5% of all visceral artery aneurysms. They can be an incidental finding or they can present with haemorrhagic shock, abdominal pain and rarely with obstructive jaundice or hyperamylasaemia. The diagnosis is usually made with an angiography. Variable treatment options are available depending on the patient's fitness and haemodynamic stability.

Aortic and splanchnic artery aneurysms: Unusual causes of biliary obstruction - A retrospective cohort from literature

Mechanical obstruction of the biliary tree and resultant stasis are the cornerstone of a spectrum of diseases ranging from biliary colic to fulminant cholangitis. Infrequently acquired abnormalities of the abdominal vasculature can lead to biliary obstruction. In 2010, we reported a case of acute cholangitis resulting from compression of extra hepatic bile duct by an abdominal aortic aneurysm (AAA). We subsequently conducted a follow up scoping review of literature to identify other cases of acquired abdominal arterial abnormalities resulting in biliary obstruction looking at their management and outcomes. The articles were independently reviewed by two of the authors and pertinent data was extracted. The data was divided on an anatomic basis into two groups: one with primary aortic pathology and one with splanchnic vessel pathology. We identified 39 cases of biliary obstruction secondary to acquired aortic or splanchnic vessel abnormalities; 16 were caused by AAAs and 23 by splanchnic vessels. The cases were managed via conservative, endoscopic, endovascular or open surgical options based on the available technology and expertise. Although uncommon, recognition of aortic and splanchnic arterial abnormalities as a potential cause of biliary obstruction is important as management entails not only cautious decompression of the biliary tree but also addressing the underlying vascular pathology. We recommend that extrinsic biliary compression by an aneurysm or pseudoaneurysm be considered among the differential diagnosis in patients presenting with biliary obstruction and a known lesion of the abdominal vasculature.

Compressive hematoma due to pseudoaneurysm of the right hepatic artery: a rare cause of obstructive jaundice after single-port cholecystectomy

Single-port laparoscopic cholecystectomy is considered as a form of natural orifice surgery with better esthetic outcomes than traditional laparoscopic cholecystectomy. It is a technically demanding procedure, and no adequately powered trial has assessed the safety of this technique. Vascular injuries are less common than bile duct injuries during this procedure, but they can be rapidly fatal. The development of a right hepatic artery pseudoaneurysm is a rare but serious complication associated with single-port laparoscopic cholecystectomy. Two weeks following a single-port laparoscopic cholecystectomy for angiocholitis, a 40-year-old male patient presented with obstructive jaundice and persistent abdominal pain. The diagnosis of compressive hematoma due to a ruptured right hepatic artery pseudoaneurysm was confirmed by computed tomography scan and angiography. It was successfully treated by selective embolization of the right hepatic artery. In our experience, endovascular management was a noninvasive and effective treatment of ruptured pseudoaneurysms.

Jaundice as a Rare Indication for Aortic Aneurysm Repair

Compression of adjacent anatomic structures by an abdominal aortic aneurysm (AAA) can result in a variety of symptoms. We describe the case of an 88-year-old Caucasian woman with jaundice, elevated laboratory parameters for extrahepatic and intrahepatic cholestasis, and concomitant juxtarenal AAA compressing the liver hilum. Following exclusion of other common causes for cholestasis, the patient was considered to have a symptomatic AAA. Open abdominal aortic surgery revealed a contained rupture and was repaired. Obstructive jaundice secondary to a compromising AAA is a rare condition and to the best of our knowledge has not been reported to date.

Obstructive jaundice secondary to multiple hepatic artery aneurysms in a 14-year-old boy with neurofibromatosis type 1

Neurofibromatosis type 1 is the most common inherited disorder of the nervous system, affecting approximately 1 in 3,000 people. A small but significant subset of these patients develop vasculopathies. We present the first reported case of neurofibromatosis type 1 presenting with obstructive jaundice secondary to multiple hepatic artery aneurysms. Therapy included staged coil embolization of the hepatic artery aneurysms and resection of a large retroperitoneal neurofibroma.

Obstructive jaundice and cholangitis caused by an arterial ring of the proper hepatic artery around the common bile duct

Background

Many different benign and malignant diseases can cause obstruction of the extrahepatic biliary duct. One of the more serious complications of biliary obstruction is cholangitis leading to emergency decompression. Anatomic variations are frequent in this region; however, it has rarely been reported that the extrahepatic bile duct is compressed by the arterial vessels.

Case Report

We present the case of a 68-year-old woman who was admitted through the emergency department of our hospital with jaundice, abdominal pain and fever. Biochemical analyses of liver function showed increased value of AST (113 IU/L) and AST (128 IU/L). Total bilirubin was 5.88 mg/dl, conjugated bilirubin was 3.00 mg/dl, and alkaline phosphatase was 393 IU/L. We performed abdominal ultrasound (US), magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) imaging. Multislice CT angiography showed that the arterial ring of the common hepatic artery around the common bile duct (CBD) originated from the superior mesenteric artery. Cholecystectomy and intraoperative cholangiography were performed, as well as decompression and lavage of the biliary tree. Escherichia coli was identified from bile. Dissection of the hepatoduodenal ligament confirmed that the proper hepatic artery made a vascular ring around the CBD. Finally, a T tube was placed into the CBD. During 5 years of follow-up the patient has been without recurrent episodes of jaundice. In such cases dissection of the proper hepatic artery from the common hepatic duct is the treatment of choice.

Conclusions

If there are signs of cholangitis decompression and lavage of the biliary tree with “T”, drainage should be performed. Vascular malformations should be considered as a possible cause of extrahepatic biliary obstruction. CT angiography may be helpful in identifying these malformations.

[An unusual cause of obstructive jaundice: giant gastroduodenal artery aneurysm]

Visceral artery aneurysms are rare vascular lesions. Hepatic aneurysms are the second most common type of visceral aneurysm after those of the splenic artery. These aneurysms often have a nonspecific clinical presentation and are difficult to diagnose before rupture. Because the natural course of hepatic aneurysms leads to rupture, with a high rate of morbidity and mortality, their early diagnosis is essential for surgical correction. We report a case of obstructive jaundice caused by a 7-cm gastroduodenal artery aneurysm in which the diagnosis was suggested by abdominal computed tomography and magnetic resonance cholangiography and was confirmed by angiography. The patient was surgically treated. In the following 48 h he presented ischemic-based acute hepatic failure and underwent left hepatic lobe resection. The patient finally died from a pulmonary thromboembolism.