INTRODUCTION: Pseudoaneurysm of the cystic artery is a rare complication following laparoscopic cholecystectomy. We report a case of pseudoaneurysm of the cystic artery and hemobilia as a late complication of this operation.
CASE PRESENTATION: A 33-year-old African American male presented to the emergency room with nausea and vomiting blood clots that started the same afternoon. He had a medical history of sickle cell trait, rheumatoid arthritis, choledocholithiasis and had an ERCP and laparoscopic cholecystectomy 2 months prior to admission. His hemoglobin was 5.9g/dl on arrival. He had significant right upper quadrant abdominal pain. He was admitted to the medical ICU and the gastroenterology service was consulted. An initial EGD did not reveal any source of bleed. A few hours after the EGD he vomited more than 1 liter bright red blood. He was intubated for airway protection and placed on mechanical ventilation. An emergent EGD again, did not reveal the source of bleed in the stomach. The duodenal was successfully intubated and careful inspection of the duodenum did not show any obvious lesions in both, the first and second portions of the duodenum. The major papilla was visualised and there was no overlying clot on it. Bile was seen draining draining through the major papilla. Emergent superior mesenteric, inferior mesenteric and celiac axis arteriograms were performed by interventional radiology that showed gross extravasation at the region of the stump of the cystic artery. This was successfully embolised and a subsequent angiogram showed no more extravasation. During his admission stay, he required 10 units of packed red cells. After embolisation, there no more episodes of bleeding and he was discharged home.
DISCUSSIONS: Cystic artery pseudoaneurysm which developed following a cholecystectomy and resulting in upper gastrointestinal bleeding is a rare entity, with only four cases described in the literature . The symptoms may appear in the early postoperative period or as late as 120 days after surgery. Among the possible causes are the excessive use of electrocautery during the dissection at the infundibulum of the gallbladder, causing thermal injury to the vascular wall, and erosion of the inner wall of the cystic artery caused by contact with the tip of the metal clip used to occlude the cystic duct . The classical triad of upper gastrointestinal bleeding, pain in the right upper quadrant and obstructive jaundice described by Quincke is present in about a third of the patients. Even though our patient demonstrated gross extravastion of contrast, the presence of a dilated cystic artery stump on angiogram following cholecystectomy is an “ominous sign”, even in the absence of active extravasation of contrast.
CONCLUSION: GI bleed constitutes a significant proportion of MICU admissions. Intensivists should be aware that cystic artery bleeds can present as a massive GI bleed. It should definitely be considered in the differential diagnosis of upper GI bleed in a patient with previous cholecystectomy, more so if EGD fails to locate the bleeding source. Emergent angiography and embolization can life-saving.
DISCLOSURE: Somnath Ghosh, No Financial Disclosure Information; No Product/Research Disclosure Information