1288 Cystic Artery Pseudo-Aneurysm: A Rare Cause of Hemobilia and Jaundice

INTRODUCTION: Aneurysms of the hepatic artery or its branches are rare, representing 0.01-2% of all arterial aneurysms.1 Causes of cystic artery aneurysms include abdominal trauma and intra-abdominal inflammatory processes such as cholecystitis.2 We present a case of gastrointestinal bleeding, jaundice and colicky right upper quadrant abdominal pain (Quincke's clinical triad) as a result of a ruptured pseudo-aneurysm of cystic artery. CASE DESCRIPTION/METHODS: A 79-year-old white man with a past history of cholecystectomy presented with colicky right upper quadrant pain, jaundice and melena. Physical examination showed stable vital signs. He had icterus. He was mildly tender in the epigastrium and right upper quadrant on palpation. His CBC showed a white cell count of 16.5 K/UL, hemoglobin 13.8 GM/DL, and hematocrit 42%. LFTs showed total bilirubin of 7.50 MG/DL, direct bilirubin 5.30 MG/DL, AST of 379 IU/L, ALT of 798 IU/L, and alkaline phosphatase was 337 IU/L. An ERCP was performed. The ERCP showed blood clots at the ampulla. Cholangiogram showed multiple filling defects consistent with blood clots. This was treated with placement of biliary stent. CT showed hemorrhage next to a fusiform pseudo-aneurysm measuring 13 × 6 mm, which appeared to arise in the region of the cystic artery. Embolization of pseudo-aneurysm resolved the patient's symptoms. DISCUSSION: Pseudo-aneurysm of cystic artery after laparoscopic cholecystectomy is rare. One report identified 27 published cases.3 It can occur up to 120 days after surgery.4 Among the possible causes are the excessive use of electrocautery and erosion of the cystic artery caused by the metal clip used to occlude the cystic duct.5 Pseudo-aneurysm of the hepatic artery or its branches presents with hemobilia in about 20% of cases in the early postoperative period.4,6 The classic triad of upper gastrointestinal bleeding, pain in the right upper quadrant and obstructive jaundice described by Quincke is present in 32% of patients.7,8 In our patient, the possibility of a pseudo-aneurysm was only considered after imaging. Angiography established the diagnosis. Doppler ultrasound is an alternative means of detecting the aneurysm.9 In patients with gastrointestinal bleeding, EGD and ERCP may be performed before arteriography.10,11 Transarterial embolisation is the treatment of choice in the presence of hemorrhage.6,10,12 When there is compression of the bile duct or a fistula or failure of embolisation, surgery is needed to repair or ligate the artery involved.7