D0075 - Cystic Artery Aneurysm Mimicking Mirizzi Syndrome: A Rare Case Complicated by Severe Gangrenous Cholecystitis

Amit Sah, MD¹, Matthew Gulau, MD¹, Lesley-Ann G. McCook, MD², Claudia Tejera Quesada, MD¹, Jose Proenza, MD³, Hayden Aaron, MD^3
1University of Miami/JFK Medical Center, Atlantis, FL; ²University of Miami/ JFK Medical Center Palm Beach Regional GME Consortium, Atlantis, FL; ³Veterans Affairs Medical Center, West Palm Beach, FL

Introduction: Mirizzi syndrome (MS) is a rare condition caused by an impacted gallstone at the gallbladder (gb) infundibulum causing obstructive jaundice, cholecystitis and visceral inflammation. Most reported cases of visceral aneurysms reference cystic artery pseudoaneurysms (CAP) caused by inflammation. Here we present a case of cystic artery aneurysm (CAA) mimicking neoplasm on imaging and presented as painful jaundice complicated by gangrenous cholecystitis (GC).

Case Description/Methods: 69-year-old-man with alcohol abuse presented with 2 weeks of worsening RUQ abdominal pain, vomiting, jaundice and 15 kg unintentional weight loss. Vitals were stable and he had mild RUQ tenderness with negative murphy’s sign. Pertinent labs are listed in table 1. CT was significant for hepatic mass infiltrating the gb with intrahepatic biliary duct dilation. MRCP revealed possible hepatic or celiac artery aneurysm abutting the gb causing biliary obstruction resulting in ERCP and biliary stent placement. CTA abdomen, doppler US liver and IR angiogram confirmed large cystic artery aneurysm adherent to gb wall. Despite antibiotics, he was clinically deteriorating with worsening leukocytosis, fever and Klebsiella pneumoniae bacteremia. With suspicion of possible fistula between gb and CAA, and with multidisciplinary recommendations, he underwent exploratory laparotomy with cholecystectomy. Intraoperative findings revealed CAA fistulizing into gb with haemobilia and gangrenous cholecystitis with gallstone. Pathology and serum markers were negative for neoplasm. He survived this complicated case without complication.

Discussion: Similar to MS, CAA can cause mass effect leading to obstructive jaundice, cholangitis and in rare cases haemobilia and life-threatening hemorrhage. Like CAP, the etiology of CAA is postulated to be an inflammation from cholecystitis, pancreatitis, intraabdominal trauma or iatrogenic injury. Our patient had gallstone, hence MS complicated by cholangitis and gangrenous cholecystitis is likely etiology for CAA. Angiographic embolization or open surgical repair are reported modalities of its management with mortality around 2%. GC alone carries mortality as high as 22% and concurrent CAA with cholangitis definitely makes prognosis guarded. Initial CT abdomen was suspicious for a neoplasm hence in a resource limited country and without multidisciplinary evaluation with appropriate imaging modalities, it could easily be mismanaged as malignancy, which could lead to an unfavorable prognosis for the patient.



Disclosures:


Amit Sah, MD¹, Matthew Gulau, MD¹, Lesley-Ann G. McCook, MD², Claudia Tejera Quesada, MD¹, Jose Proenza, MD³, Hayden Aaron, MD³. D0075 - Cystic Artery Aneurysm Mimicking Mirizzi Syndrome: A Rare Case Complicated by Severe Gangrenous Cholecystitis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.