Cystic artery pseudo-aneurysm: a complication of xanthogranulomatous cholecystitis

An unusual case of acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction: a case report and review of literature

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.

Laparoscopic cholecystectomy after transcatheter arterial embolisation for haemobilia due to a pseudoaneurysm in the gallbladder: A case report

Pseudoaneurysms of the cystic artery are a rare but significant complication of acute cholecystitis. Laparoscopic cholecystectomy may be a safe alternative to open cholecystectomy in such cases. We report the case of a female patient in her seventies, who presented with anaemia, jaundice, and hepatic dysfunction during hospitalisation for right knee pyogenic arthritis. The patient had no pain in the right upper quadrant. Her serum haemoglobin level was 6.5 g/dL, and upper gastrointestinal endoscopy revealed no abnormalities. Six days later, jaundice worsened, and endoscopic retrograde cholangiopancreatography revealed bloody bile. An endoscopic biliary drainage tube was inserted at the discretion of the gastroenterology department. Contrast-enhanced computed tomography revealed a haematoma in the gallbladder and a pseudoaneurysm in the lateral wall of the gallbladder. On the same day, the endoscopic biliary drainage tube was replaced with an endoscopic nasobiliary drainage tube, which indicated the degree of haemorrhage and enabled lavage of the lumen in cases of obstruction. The next day, angiography revealed a pseudoaneurysm of the deep branch of the cystic artery and coil embolisation was performed at the periphery of the cystic artery. Uninterrupted laparoscopic cholecystectomy was performed. Although laparoscopic cholecystectomy is difficult when bleeding is uncontrolled, it was safely performed following haemostasis using transcatheter arterial embolisation. Laparoscopic cholecystectomy is feasible in haemodynamically stable patients with cystic artery pseudoaneurysms after transcatheter arterial embolisation.

Laparoscopic treatment of an unruptured cystic artery pseudo-aneurysm in the presence of calculous emphysematous cholecystitis

Cystic artery pseudoaneurysm is a rare complication of invasive biliary procedures or of acute or chronic cholecystitis and pancreatitis. Emphysematous cholecystitis is an acute inflammatory process of the gallbladder due to gas forming organisms such as Escherichia coli and Clostridium perfringens. We report the case of a 34-year-old gentleman admitted with a 3-day history of generalized abdominal pain, vomiting and markedly raised inflammatory markers. A computed tomography scan demonstrated acute calculus cholecystitis and an incidental CAP. This was successfully treated with an emergency laparoscopic cholecystectomy. CAPs are reported in the literature as rare and are usually diagnosed after rupture with severe haemorrhage. In this report, we highlight that a non-ruptured CAP identified preoperatively can be safely managed simultaneously with a laparoscopic approach, thus avoiding the need for invasive angiographic procedures or open surgery.

Cystic Artery Pseudoaneurysm: Current Review of Aetiology, Presentation, and Management

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.

Cystic artery pseudoaneurysm-a rare complication of acute cholecystitis: review of literature

OBJECTIVE

To acquaint with the presentation and management of the cystic artery aneurysm by enriching the reviewed literature with our own experience.

BACKGROUND

Cystic artery pseudoaneurysm is an uncommon entity with varied clinical presentation. Inflammation and trauma are associated with most of the cases. Limited experience with the condition challenges the management of individual cases.

MATERIALS AND METHODS

We retrieved all the reported cases of cystic artery pseudoaneurysm, published up to December 2019, from the PubMed database and excluded those arising as postoperative complications. A total of 59 cases were analyzed, and we also included our experience of managing a case of cystic artery pseudoaneurysm.

RESULTS

Abdominal pain (77.9%) was the most common presentation followed by upper GI bleed (64.4%), while 19 patients (32.2%) had presented with classic Quincke's Triad. Most of the cases were diagnosed following the rupture of the pseudoaneurysm (n = 49, 83.05%). Fifteen patients presented with shock. Hyperbilirubinemia (59.3%) and anemia (55.9%) were the commonest laboratory findings. Although CT angiogram remains the investigation of choice, a conventional angiogram is the gold standard and sufficed as the definitive management in 20 cases. Cholecystectomy formed the definitive management in the rest of the cases. We successfully managed a middle-aged female patient of cystic artery aneurysm with xanthogranulomatous cholecystitis by open cholecystectomy.

CONCLUSION

Cystic artery pseudoaneurysms are amenable to successful management with careful evaluation and timely cholecystectomy or angioembolization or a combination of both.

Vascular disorders of the gallbladder and bile ducts: Imaging findings

Vascular disorders of the gallbladder and biliary tree are many and varied. In the acute setting, the clinical presentation of vascular conditions such as hemorrhagic cholecystitis and gangrenous cholecystitis are non-specific and rely on imaging for diagnosis and triaging for emergent surgery. These hemorrhagic and ischemic complications of acute cholecystitis are uncommon but potentially fatal. Hemorrhage into the gallbladder and biliary tree, from other causes, may itself result in acute cholecystitis. Knowledge of vascular anatomy of the gallbladder and biliary tree is essential for surgeons to prevent significant operative bleeding complications, particularly in laparoscopic cholecystectomy. The unique venous drainage of the gallbladder and biliary tree, with their connections to the portal venous system, lends itself to less well-recognised vascular phenomena such as gallbladder varices, portal biliopathy, and gallbladder bed perfusion abnormalities.

Rare case of cystic artery pseudoaneurysm

A patient with a cystic artery pseudoaneurysm (CAP) presented to the emergency department with upper abdominal and back pain. The patient also had clinical signs of sepsis. CT revealed gallstones with acute suppurative cholecystitis with a gallbladder perforation. In addition, a CAP was also suspected and subsequently diagnosed on CT angiography. The pseudoaneurysm was treated with embolisation and a cholecystostomy was performed for the gallbladder perforation. Following her acute admission, the patient underwent an elective cholecystectomy and made a good recovery post surgery.

Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review

Patient: Male, 90

Final Diagnosis: Ruptured cystic artery pseudoaneurysm

Symptoms: Epigastric pain • Fever

Medication: —

Clinical Procedure: Open cholecystectomy

Specialty: Gastroenterology and Hepatology

Transcatheter Embolization of Cystic Artery Pseudoaneurysms Secondary to Acute Cholecystitis

Cystic artery pseudoaneurysm is a rare entity most closely associated with trauma to the biliary vasculature (usually iatrogenic) or inflammation from adjacent cholecystitis. Most cases are treated intraoperatively during cholecystectomy. We describe 3 cases of cystic artery pseudoaneurysms secondary to acute cholecystitis, 2 with active hemobilia, treated with transcatheter embolization at our institution.

Management of a pseudo-aneurysm in the hepatic artery after a laparoscopic cholecystectomy

Introduction Symptomatic hepatic-artery pseudoaneurysm (HAP) after bile-duct injury (BDI) is a rare complication with a varied (but clinically urgent) presentation. Methods A prospectively maintained database of all patients with BDI at laparoscopic cholecystectomy (LC) referred to a tertiary specialist hepatobiliary centre between 1992 and 2011 was searched systematically to identify patients with a symptomatic HAP. Care and outcome of these patients was studied. Results Eight (6 men) of 236 patients with BDI (3.4%) with a median age of 65 (range: 54?6) years presented with symptomatic HAP. Median time of presentation of the HAP from the index LC was 31 (range: 13?16) days. Bleeding was the dominant presentation in 7 patients. One patient presented late (>2 years) with abdominal pain alone. Computed tomography angiography was the most useful investigation. Angioembolisation was successful in 7 patients. One patient died, and another patient developed liver infarction. Three patients (38%) developed biliary strictures after embolisation. Seven patients are alive and well at a median follow-up of 66 months. Conclusions Presentation of HAP is often delayed. A high index of suspicion is necessary for the diagnosis. Computed tomography angiography is the first-line investigation and selective angioembolisation can yield successful outcomes.

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.

An unusual cause of acute internal haemorrhage: cystic artery pseudoaneurysm secondary to acute cholecystitis

Spontaneous cystic artery haemorrhage is a rare complication of acute cholecystitis. Here we describe a case report of this unusual cause of internal haemorrhage, and discuss the pathogenesis and management strategies.

Emergency cholecystectomy and hepatic arterial repair in a patient presenting with haemobilia and massive gastrointestinal haemorrhage due to a spontaneous cystic artery gallbladder fistula masquerading as a pseudoaneurysm

BACKGROUND

Haemobilia usually occurs secondary to accidental or iatrogenic hepatobiliary trauma. It can occasionally present with cataclysmal upper gastrointestinal haemorrhage posing as a life threatening emergency. Haemobilia can very rarely be a complication of acute cholecystitis. Here we report a case of haemobilia manifesting as massive gastrointestinal haemorrhage in a patient without any prior history of biliary surgery or intervention and present a brief review of literature.

CASE PRESENTATION

A 22 year old male admitted with history suggestive of acute cholecystitis subsequently developed waxing waning jaundice and recurrent episodes of upper gastrointestinal bleed. Endoscopy showed an ulcer in the first part of duodenum with a clot, no active bleed was visible. Angiography was suggestive of a ruptured pseudoaneurysm in the vicinity of the right hepatic artery probably originating from the cystic artery. Coil embolization was tried but the coil dislodged into the right branch of hepatic artery distal to the site of pseudoaneurysm. Review of angiographic video in light of operative findings demonstrated a fistulous communication between cystic artery and gallbladder as the cause, a simultaneous cholecystoduodenal fistula was also noted. Retrograde cholecystectomy, closure of cholecystoduodenal fistula and right hepatic arteriotomy with retrieval of the endo-coil and hepatic arterial repair was performed.

CONCLUSION

Fistula between the cystic artery and gallbladder has been commonly reported to occur after laparoscopic cholecystectomy. Spontaneous fistulous communication, i.e. in the absence of any prior trauma or intervention, between cystic artery and gallbladder is rare with very few reports in literature. Aetiopathogenesis of the disease, in the context of current literature is reviewed. The diagnostic dilemma posed by the confounding finding of an ulcer in the duodenum, the iconic video angiographic depiction as also the therapeutic challenge of a failed embolization with consequent microcoil migration and primary hepatic arterial repair in the emergency situation is discussed.