Faisal Mahfooz, MD, Jimmy Giang, DO, Karolina Siniakowicz, DO, Atul Vahil, MD; Parkview Medical Center, Pueblo, CO
Introduction: Laparoscopic cholecystectomy is considered the gold standard for cholecystitis and symptomatic cholelithiasis. However, it poses a risk of bile duct injury and injury to the right (R) hepatic artery when compared to the open operation. While injuries including bile leakage of aberrant ducts, cystic stump injury, or main bile duct injury have been documented, hemobilia secondary to hepatic artery pseudoaneurysm is a rare complication of laparoscopic cholecystectomy. This case represents delayed gastrointestinal bleeding sustained from laparoscopic cholecystectomy with injury to the common bile duct (CBD).
Methods: An 82 year-old male presented to the hospital with mid-epigastric abdominal pain and melena beginning two months after a cholecystectomy that was converted to an open procedure secondary to complications from a gangrenous gallbladder. During that procedure, a leak within the Duct of Luschka noted and closed with placement of a T-tube (draining tube). This would stay in until two weeks prior to admission. On initial presentation, the patient had an elevated temperature of 100.3 F. Initial hemoglobin (Hgb) was 13 g/dL, which dropped to 9 g/dL after 24 hours. Liver enzymes were elevated (total bilirubin 5.4, AST 194, ALT 149, and alkaline phosphatase 188). Computed tomography revealed dilation of both the intra and extrahepatic bile ducts and hyperdense material within an 18 mm dilated common bile duct. Magnetic resonance cholangiopancreatography confirmed the findings above. Endoscopic retrograde cholangiopancreatography revealed blood emanating from the ampullary orifice. A small sphincterotomy was performed and a 10 french x 5 cm plastic biliary stent was placed. Interventional radiology was consulted and angiography revealed a large pseudoaneurysm of a branch of the R hepatic artery in the region of the cystic artery communicating with the bile duct. This was subsequently embolized. The patient’s Hgb stabilized and he was subsequently discharged home. Discussion: R hepatic artery pseudoaneurysm is an uncommon complication from laparoscopic cholecystectomy, however, the incidence is increased if there is injury to the bile duct during the operation. This case raises the awareness of hemobilia secondary to right hepatic artery pseudoaneurysm as an important bile duct injury that can predispose the patient to long-term complications. Prompt recognition using radiographic and endoscopic modalities helped make a diagnosis which lead to the appropriate management.
Endoscopic view with side-viewing duodenoscope showing hemobilia.
CT abdomen and pelvis showing the hepatic artery pseudoaneurysm communicating with the biliary system.
Another view of the right hepatic artery pseudoaneurysm communicating with the biliary system on CT abdomen and pelvis.
Disclosures: Faisal Mahfooz indicated no relevant financial relationships. Jimmy Giang indicated no relevant financial relationships. Karolina Siniakowicz indicated no relevant financial relationships. Atul Vahil indicated no relevant financial relationships.