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Sibria D, Elawad M, Aker LJA, Barah A, Almokdad O, Ladumor SB, Mohamed MA, Al Rashid AA, Alahmad YM, Kambal A. Cystic Artery Stump Pseudoaneurysm Following Laparoscopic Cholecystectomy: A Case Report. Cureus 2024; 16:e64551. [PMID: 39144866 PMCID: PMC11322850 DOI: 10.7759/cureus.64551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Cystic artery stump pseudoaneurysm (CASP) is a potentially life-threatening condition that can be related to multiple etiologies, especially the iatrogenic factor owing to the increased number of hepatobiliary procedures. Most patients present with haemobilia. Here we report a successfully managed case of CASP that initially complained of right upper abdominal pain. A 38-year-old patient developed bile duct injury after laparoscopic cholecystectomy (LC) which was identified by magnetic resonance cholangiopancreatography (MRCP). Later, she developed haemobilia due to CASP which was then treated by trans-arterial embolization (TAE). CASP is a rare complication of post-LC, yet potentially life-threatening, with possible delayed complications occurring months to years after the surgery. Clinicians and radiologists should be aware of this important entity and its variable manifestations to facilitate early treatment.
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Affiliation(s)
- Dalal Sibria
- Radiology Department, Hamad Medical Corporation, Doha, QAT
| | - Mohamed Elawad
- Radiology Department, Hamad Medical Corporation, Doha, QAT
| | - Loai J A Aker
- Radiology Department, Hamad Medical Corporation, Doha, QAT
| | - Ali Barah
- Radiology Department, Hamad Medical Corporation, Doha, QAT
| | - Omran Almokdad
- Radiology Department, Hamad Medical Corporation, Doha, QAT
| | | | | | | | | | - Aalaa Kambal
- Radiology Department, Hamad Medical Corporation, Doha, QAT
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Lampropoulos C, Markopoulos G, Tsochatzis S, Bellou A, Amanatidis T, Kehagias D, Papadopoulos G, Kehagias I. Symptomatic pseudoaneurysms following laparoscopic cholecystectomy: Focus on an unusual and dangerous complication. J Minim Access Surg 2021; 17:450-457. [PMID: 34558424 PMCID: PMC8486062 DOI: 10.4103/jmas.jmas_164_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/03/2020] [Accepted: 09/20/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) has been associated with an increase in the incidence of biliary and vascular injuries. Pseudoaneurysms (PAs) following LC are rare life-threatening events with limited available experience regarding diagnosis and treatment. MATERIALS AND METHODS An extensive review of literature during a 26-year period (1994-2020) using MEDLINE® database and Google Scholar® academic search engine revealed 134 patients with at least one symptomatic PA following LC. RESULTS Nearly. 81% of patients with PAs become symptomatic during the first 8 weeks following LC. The most common symptoms were gastrointestinal bleeding (74%) and abdominal pain (61%). In 28% of cases, there was a concomitant bile duct injury or leak from the cystic duct stump, whereas in about one-third of cases, PAs presented following an uneventful LC. The most common involved arteries were the right hepatic artery (70%), the cystic artery (19%) or both of them (3%). Trans-arterial embolisation was the favoured first-line treatment with a success rate of 83%. During a median follow-up of 9 months, the mortality rate was 7%. CONCLUSION Clinicians should be aware of the PA occurrence following LC. Prompt diagnosis and treatment are essential.
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Affiliation(s)
| | | | | | - Aggeliki Bellou
- Department of Pulmonary Medicine, General University Hospital of Patras, Patras, Greece
| | | | - Dimitrios Kehagias
- Department of Surgery, General University Hospital of Patras, Patras, Greece
| | | | - Ioannis Kehagias
- Department of Surgery, General University Hospital of Patras, Patras, Greece
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Berry R, Weissman S, Mehta TI, Vartanian T, Tabibian JH. Hemobilia in the Setting of Billroth II Anatomy and Recurrent Gastric Adenocarcinoma. J Gastrointest Cancer 2021; 52:328-331. [PMID: 32572812 DOI: 10.1007/s12029-020-00437-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rani Berry
- Department of Internal Medicine, UCLA Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - Simcha Weissman
- Department of Medicine, Hackensack University-Palisades Medical Center, North Bergen, NJ, USA
| | - Tej I Mehta
- Department of Radiology, University of South Dakota, Sioux Falls, SD, USA
| | - Tara Vartanian
- Department of Internal medicine, Adventist Health White Memorial, Los Angeles, CA, USA
| | - James H Tabibian
- Division of Gastroenterology, Olive View-UCLA Medical Center, 14445 Olive View Dr., 2B-182, Sylmar, CA, 91342, USA.
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Kurniawan K, Wibawa IDN, Somayana G, Mariadi IK, Mulyawan IM. Massive hemobilia caused by rupture of gastroduodenal artery pseudoaneurysm, a delayed complication of laparoscopic cholecystectomy: a case report. J Med Case Rep 2021; 15:331. [PMID: 34210350 PMCID: PMC8252212 DOI: 10.1186/s13256-021-02915-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/18/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hemobilia is a rare cause of upper gastrointestinal bleeding that originates from the biliary tract. It is infrequently considered in diagnosis, especially in the absence of abdominal trauma or history of hepatopancreatobiliary procedure, such as cholecystectomy, which can cause arterial pseudoaneurysm. Prompt diagnosis is crucial because its management strategy is distinct from other types of upper gastrointestinal bleeding. Here, we present a case of massive hemobilia caused by the rupture of a gastroduodenal artery pseudoaneurysm in a patient with a history of laparoscopic cholecystectomy 3 years prior to presentation. CASE PRESENTATION A 44-year-old Indonesian female presented to the emergency department with complaint of hematemesis and melena accompanied by abdominal pain and icterus. History of an abdominal trauma was denied. However, she reported having undergone a laparoscopic cholecystectomy 3 years prior to presentation. On physical examination, we found anemic conjunctiva and icteric sclera. Nonvariceal bleeding was suspected, but esophagogastroduodenoscopy showed a blood clot at the ampulla of Vater. Angiography showed contrast extravasation from a gastroduodenal artery pseudoaneurysm. The patient underwent pseudoaneurysm ligation and excision surgery to stop the bleeding. After surgery, the patient's vital signs were stable, and there was no sign of rebleeding. CONCLUSION Gastroduodenal artery pseudoaneurysm is a rare complication of laparoscopic cholecystectomy. The prolonged time interval, as compared with other postcholecystectomy hemobilia cases, resulted in hemobilia not being considered as an etiology of the gastrointestinal bleeding at presentation. Hemobilia should be considered as a possible etiology of gastrointestinal bleeding in patients with history of cholecystectomy, regardless of the time interval between the invasive procedure and onset of bleeding.
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Affiliation(s)
- Kurniawan Kurniawan
- Department of Internal Medicine, Faculty of Medicine, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
| | - I Dewa Nyoman Wibawa
- Gastroentero-Hepatology Division, Department of Internal Medicine, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
| | - Gde Somayana
- Gastroentero-Hepatology Division, Department of Internal Medicine, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
| | - I Ketut Mariadi
- Gastroentero-Hepatology Division, Department of Internal Medicine, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia.
| | - I Made Mulyawan
- Digestive Surgery Division, Department of General Surgery, Faculty of Medicine, Udayana University/Sanglah General Hospital, Denpasar, Bali, Indonesia
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Romano L, Lazzarin G, Varrassi M, Di Sibio A, Vicentini V, Schietroma M, Carlei F, Giuliani A. Haemobilia secondary to a cystic artery pseudoaneurysm as complication of VLC. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021125. [PMID: 33944818 PMCID: PMC8142751 DOI: 10.23750/abm.v92is1.10821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The laparoscopic approach has become the gold standard for cholecystectomy. However, it could have some major complications. Among them, it can be considered postoperative pseudoaneurysms of the cystic or hepatic arteries. Haemobilia secondary to a cystic artery pseudoaneurysm is extremely rare. CASE REPORT Here we present a case from our centre of haemobilia in association with a cystic artery pseudoaneurysm, as a late complication of VLC. An 18-year-old girl underwent laparoscopic cholecystectomy; during surgery, due to viscero-perietal tight adhesions and due to the close proximity of the cystic duct to the biliary ducts, we suspected a bile duct injury. So, decision was taken to convert to open surgery: a suture was performed to repair the coledocic duct injury and an endoscopic papillotomy was performed with subsequent positioning of an endoscopic plastic biliary endoprothesis at the hepatocholedochus. One month after surgery, the patient showed clinical signs of hypovolemic shock. She underwent Computed Tomography Angiography, showing a possible arterial lesion, just adjacent to surgical clip. Therefore, patient underwent angiographic examination, which confirmed an 8 mm pseudoaneurysm arising from cystic artery, just adjacent to surgical clips. Superselective catheterization of vessel was performed, and two coils were released, until obtaining complete exclusion of the vascular lesion. The patient was discharged five days after procedure, with good general condition. CONCLUSION Pseudoaneurysms of the cystic artery are uncommon entities, rarely reported in the literature, and often caused by cholecystitis or iatrogenic biliary injury. All conditions that are responsible for vessels' injuries could also cause haemobilia. Even if pseudoaneurysm of cystic artery with haemobilia is a rare event, it has to be considered as a complication of VLC. Angiographic approach should be the treatment of choice.
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Affiliation(s)
- Lucia Romano
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila.
| | - Gianni Lazzarin
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila.
| | - Marco Varrassi
- Department of Radiology, S. Salvatore Hospital, L'Aquila.
| | | | - Vincenzo Vicentini
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila.
| | - Mario Schietroma
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila.
| | - Francesco Carlei
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila.
| | - Antonio Giuliani
- Department of Surgery, Department of Applied Clinical Science and Biotechnology, University of L'Aquila, L'Aquila.
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Traa AC, Hoven-Gondrie ML, Diederik AL. A pseudoaneurysm of the right hepatic artery treated successfully with a stent graft - A case report. Int J Surg Case Rep 2020; 77:407-411. [PMID: 33220658 PMCID: PMC7688995 DOI: 10.1016/j.ijscr.2020.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 10/27/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022] Open
Abstract
Haemobilia caused by pseudoaneurysms of the right hepatic artery or the cystic artery are rare with incidences up to 0.6%. Pathogenesis of pseudoaneurysms of the cystic or hepatic arteries are described to be cholecystectomy or cholecystitis related. Embolization is considered the golden standard. However, stent grafts should be considered a minimal invasive and effective alternative after failed embolization in pseudoaneurysms.
Introduction Haemobilia caused by pseudoaneurysms of the right hepatic or cystic artery is rare. Haemobilia classically causes gastro-intestinal hemorrhage, jaundice and upper abdominal pain. Presentation of case A 76-year old female underwent laparoscopic cholecystectomy because of a severe acute on chronic cholecystitis. A massive arterial bleeding occurred during surgery, which was controlled with hemoclips. Approximately one week after surgery the patient developed severe colic pains and cholestatic liver enzyme alterations. Endo-ultrasound showed normal-width bile ducts, however during a subsequent ERCP haemobilia was observed. On computed tomography a pseudoaneurysm of the right hepatic artery was seen. Selective embolization was initially successful, however, a rebleed was observed two weeks later and a 6 × 50 mm Viabahn stent graft was placed in the right hepatic artery uneventfully. The patient remained free of complaints during 3-years of follow-up. Discussion Pseudoaneurysms of the cystic or hepatic arteries are described to be cholecystectomy or cholecystitis related. The etiology of the pseudoaneurysm in this case can be inflammatory or iatrogenic. Embolization is the golden standard in pseudoaneurysm treatment. Stent graft implantation has not been frequently described as an alternative option to surgery after a failed attempt of embolization. Conclusion This case report presents a probable cholecystitis related pseudoaneurysm of the right hepatic artery, which caused haemobilia after cholecystectomy. The pseudoaneurysm was successfully eliminated with a stent graft after embolization had failed. Stent grafts should be considered a minimal invasive and effective alternative after failed embolization of a pseudoaneurysm.
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Affiliation(s)
- Amber C Traa
- Department of Surgery, Gelderse Vallei Hospital, Ede, the Netherlands.
| | | | - Arjen L Diederik
- Department of Radiology, Gelderse Vallei Hospital, Ede, the Netherlands
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Zhornitskiy A, Berry R, Han JY, Tabibian JH. Hemobilia: Historical overview, clinical update, and current practices. Liver Int 2019; 39:1378-1388. [PMID: 30932305 DOI: 10.1111/liv.14111] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/16/2022]
Abstract
Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosis of hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.
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Affiliation(s)
- Alex Zhornitskiy
- Department of Internal Medicine, UCLA-Olive View Medical Center, Sylmar, California
| | - Rani Berry
- Department of Internal Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - James Y Han
- Department of Internal Medicine, University of California, Irvine, California
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California
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Berry R, Han JY, Kardashian AA, LaRusso NF, Tabibian JH. Hemobilia: Etiology, diagnosis, and treatment ☆. LIVER RESEARCH 2018; 2:200-208. [PMID: 31308984 PMCID: PMC6629429 DOI: 10.1016/j.livres.2018.09.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon but important cause of gastrointestinal hemorrhage. Reports of hemobilia date back to the 1600s, but due to its relative rarity and challenges in diagnosis, only in recent decades has hemobilia been more critically studied. The majority of cases of hemobilia are iatrogenic and caused by invasive procedures involving the liver, pancreas, bile ducts and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other leading causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described (i.e. Quincke's triad), but this is present in only 25%-30% of patients with hemobilia. Therefore, prompt diagnosis depends critically on having a high index of suspicion, which may be based on a patient's clinical presentation and having recently undergone (peri-) biliary instrumentation or other predisposing factors. The treatment of hemobilia depends on its severity and suspected source and ranges from supportive care to advanced endoscopic, interventional radiologic, or surgical intervention. Here we provide a clinical overview and update regarding the etiology, diagnosis, and treatment of hemobilia geared for specialists and subspecialists alike.
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Affiliation(s)
- Rani Berry
- Department of Internal Medicine, UCLA Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - James Y. Han
- Department of Internal Medicine, University of California Irvine, Irvine, CA, USA
| | - Ani A. Kardashian
- UCLA Gastroenterology Fellowship Training Program, Vatche and Tamar Manoukian Division of Digestive Diseases, Los Angeles, CA, USA
| | - Nicholas F. LaRusso
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA,Corresponding author. Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA., (J. H. Tabibian)
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