Identifying the presence of hemobilia can be clinically important since it might change the therapeutic approach to patient management. Here, we report a 56-year-old man with clinical symptoms of acute cholecystitis. Multidetector-row computed tomography of the abdomen showed a ruptured pseudoaneurysm arising from the right hepatic artery. Angiography, with transarterial coil embolization of the pseudoaneurysm, was performed before surgery to reduce the risk of hemostatic complications

Chang Hsien Liu

De-Chuan Chan

Hsien-He Hsu

Shih-Hung Tsai

Wei-Chou Chang

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 47www.signavitae.comJaundice, occult blood and acute cholecystitis: hemobilia as the initial presentation of acute cholecystitis complicated by a pseudoaneurysmABSTRACTIdentifying the presence of hemobilia can be clinically important since it might change the therapeutic approach to patient management. Here, we report a 56-year-old man with clinical symptoms of acute cholecystitis. Multidetector-row compu-ted tomography of the abdomen showed a ruptured pseudoaneurysm arising from the right hepatic artery. Angiography, with transarterial coil embolization of the pseudoaneurysm, was performed before surgery to reduce the risk of hemostatic complications.WEI-CHOU CHANG (  )Department of RadiologyTri-Service General Hospital325 Cheng-Kung Road, Sec. 2Taipei, 114, TaiwanPhone: +886-2-8792-7244Fax: +886-2-8792-7245E-mail: chougo2002@yahoo.com.twSHIH-HUNG TSAIDepartment of Emergency Medicine DE-CHUAN CHANDepartment of SurgeryCHANG-HSIEN LIOU •HSIEN-HE HSU •WEI-CHOU CHANGDepartment of RadiologyTri-Service General Hospital National Defense Medical CenterSHIH-HUNG TSAI • DE-CHUAN CHAN • CHANG HSIEN LIU • HSIEN-HE HSU • WEI-CHOU CHANGCASE REPORT   SIGNA VITAE 2011; 6(1): 47 - 49Key words: pseudoaneurysm, hepa-tic artery, hemobilia, multidetector-row computed tomography, transar-terial embolizationIntroductionHemobilia can be easily missed without a high index of suspicion. However, identifying the presence of hemobilia, in a patient with acute cholecystitis, can be crucial since it might alter the thera-peutic approach. We report a patient who was found to have occult blood in the stool and hyperbilirubinemia, in addition to classical physical and sono-graphic findings of acute cholecystitis. Enhanced computed tomography (CT) of the abdomen suggested the diagno-sis of acute cholecystitis complicated by a pseudoaneurysmal formation of the right hepatic artery. Trans-arterial embolization (TAE) was performed to avoid potential haemostatic complica-tions during surgery.Case reportA 56-year-old man presented to our emergency department with a 2-day history of intermittent right-upper-qua-drant abdominal pain, passage of tarry stools (melena) and fever. He denied having any history of trauma, systemic or family illness. Physical examination disclosed a fever (38.3oC), mildly icte-ric sclera and a positive Murphy’s sign. Laboratory examinations revealed leu-cocytosis (16,500 /mm3 with segmen-ted neutrophils of 89.6%), normocytic anemia (11.3 mg/dL), elevated alanine aminotransferase (57 U/L), and hyper-bilirubinemia (direct bilirubin 2.1mg/dL, total bilirubin 3.2 mg/dL, normal 0–0.8 mg/dL). There was a positive stool guaiac test that confirmed the presence of fecal occult blood. The remaining laboratory tests, including a platelet count, amylase and albumin levels, prothrombin time/partial throm-boplastin time and renal function, were normal. An ultrasound of the whole abdomen revealed multiple gallstones with acoustic shadowing, increased gallbladder wall thickness and “sono-graphic” Murphy’s sign, confirming the diagnosis of acute cholecystitis. However, in view of the findings of hyperbilirubinemia, a diagnosis of 48 www.signavitae.comcholedocholithiasis or ascending cho-langitis should be suspected; in addi-tion, the presence of melena raised the concern of hemobilia. An enhanced multidetector-row computed tomo-graphy (MDCT) of the abdomen was performed and was consistent with the sonographic findings of acute chole-cystitis. A low-attenuation mass just medial to the gallbladder in the non-enhancing imaging was noted. The post-enhanced imaging identified that the mass had the same high attenuati-on as the aorta, indicating the presen-ce of a vascular lesion. The reformatted CT images, using a volume rendering technique, showed a giant saccular aneurysm, measuring 2.9x3.0x3.7 cm, arising from the right hepatic artery (figure 1a). Dilatation of the intra-hepa-tic ducts was also demonstrated by the coronal reconstructed CT images (figure 1b). Digital subtraction angio-graphy further confirmed the diagnosis of pseudoaneurysm of the right hepatic artery. Trans-arterial embolization with platinum coil (Fibered platinum coil, Boston Scientific, USA) was performed to avoid haemostatic complications during surgery (figures 2a and 2b). Exploratory laparotomy with cholecy-stectomy was performed subsequently. During dissection, the gallbladder reve-aled hematic content with clots, and an ovoid vascular structure was dissected from the gallbladder’s wall. The patient had an uncomplicated post-operative course. DiscussionHemobilia, which denotes an abnormal communication between a vessel of the hepatosplenic circulation and the bili-ary system, is usually inconsequential and most of the times not even diagno-sed. Clinical presentation of hemobilia (Quinke’s triad) includes: colicky abdo-minal pain, jaundice and gastrointesti-nal bleeding. (1,2) The most common cause of hemobilia is hepatic trauma in 48% of cases, followed by infection in 28%, gall stones, aneurysms, and (rarely) hepatic tumor. Pseudoaneury-sm of the cystic or hepatic artery is a rare cause of hemobilia. (3) An anci-llary diagnostic modality should be used. Color-Doppler ultrasonography was proved to be useful in equivocal cases. (4,5) However, the use of color Doppler may not be a routine part of the procedure during whole abdominal scanning; without the use of a multi-planar approach to avoid obscuration by the acoustic shadow, the diagno-sis of pseudoaneurysm may be easi-ly missed, especially if one does not harbor a high index of suspicion. On axial arterial phase CT, pseudoane-urysms appear as well defined, focal enhancing lesions that may simula-te hypervascular tumors. MDCT with image processing can easily delineate the size and extent of the aneurysm and establishes communication with its supplying artery. (6,7) Thus, MDCT can facilitate clinical decision-making of pre-operative TAE and planning the surgical approach. Management of patients with hemodynamic significant hemobilia is aimed at stopping the bleeding, maintaining a continuous flow of the biliary system, and curing the underlying cause. Although there is no consensus regarding the manage-ment of acute cholecystitis associated with a pseudoaneurysm, haemosta-tic complications remain a concern during surgical intervention and TAE has been suggested in some case reports. (8,9) Also, the location of the pseudoaneurysm might influence the selection of an appropriate surgical procedure. (10) In a patient who had occult blood in the stool and hyperbilirubinemia, in addi-tion to the classical findings of acute cholecystitis, hemobilia as a consequ-ence of acute cholecystitis complica-ted by a pseudoaneurysmal formation should be considered. In suspected cases, with the use of MDCT, a preo-perative diagnosis of pseudoaneurysm can easily be made to facilitate clinical decision-making of pre-operative TAE. TAE should be considered if there is concern about haemostatic complica-tions during cholecystectomy.Figure 1a. The reformatted CT image- using a volume rendering technique- showing a giant saccular aneurysm (asterisk), measuring 2.9x3.0x3.7 cm, arising from the right hepatic artery. 1b. The coronal reconstruc-ted CT image shows dilatation of the intra-hepatic ducts (arrow). There is no evidence of choledocholithiasis.Figure 2a. Digital subtraction angio-graphy confirms that the pseudoane-urysm (asterisk) is arising from the right hepatic artery. 2b. Trans-arte-rial embolization with platinum coils (arrow) was performed to totally obstruct the distal supply of the right hepatic artery. 49www.signavitae.comREFERENCES1.  Nakajima M, Hoshino H, Hayashi E, Nagano K, Nishimura D, Katada N, et al. Pseudoaneurysm of the cystic artery associated with upper gastrointestinal bleeding. J Gastroenterol. 1996;31:750-4.2. Galun D, Basari D, Leki N, Raznatovi Z, Barovi S, Bulaji P, et al. Hemobilia. Acta Chir Iugosl 2007;54:41-5.3. Strickland SK, Khoury MB, Kiproff PM, Raves JJ. Cystic artery pseudoaneurysm: a rare cause of hemobilia. Cardiovasc Intervent Radiol 1991;14:183-4.4. Barba CA, Bret PM, Hinchey EJ. Pseudoaneurysm of the cystic artery: a rare cause of hemobilia. Can J Surg 1994;37:64-6.5. Gutiérrez G, Ramia JM, Villar J, Garrote D, Ferron A, Ruiz E. Cystic artery pseudoaneurism from an evolved acute calculous cholecystitis. Am J Surg 2004;187:519-20.6. Kamel IR, Liapi E, Fishman EK.Liver and biliary system: evaluation by multidetector CT. Radiol Clin North Am 2005;43:977-97.7. Kim HC, Park SH, Park SI, Shin HC, Park SJ, Kim HH, et al.Three-dimensional reconstructed images using multidetector computed tomog-raphy in evaluation of the biliary tract. Abdom Imaging 2004;29:472-8.8. Maeda A, Kunou T, Saeki S, Aono K, Murata T, Niinomi N, et al. Pseudoaneurysm of the cystic artery with hemobilia treated by arterial embolization and elective cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9:755-8.9. Akatsu T, Hayashi S, Egawa T, Doi M, Nagashima A, Kitano M, et al. Hepatic artery pseudoaneurysm associated with cholecystitis that ruptured into the gallbladder. J Gastroenterol 2004;39:900-3.10. Akatsu T, Tanabe M, Shimizu T, Handa K, Kawachi S, Aiura K, et al. Pseudoaneurysm of the cystic artery secondary to cholecystitis as a cause of hemobilia: report of a case. Surg Today 2007;37:412-7.

Jaundice, occult blood and acute cholecystitis: hemobilia as the initial presentation of acute cholecystitis complicated by a pseudoaneurysm

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