An unusual case of acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction: a case report and review of literature.

Introduction: Cystic artery pseudoaneurysm rupture presents a rare yet potentially fatal aetiology for upper gastrointestinal (GI) bleed. While uncommon, its incidence has been rising with increased hepatobiliary surgical interventions, predominantly attributed to iatrogenic injury and rarely secondary to acute cholecystitis. Clinical manifestations typically include epigastric pain, upper GI haemorrhage, and obstructive jaundice. Due to its rarity, it is often excluded from initial differential diagnoses. Case report: This is an unusual case of a 54-year-old male who presented with acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction, in the setting of cystic artery pseudoaneurysm rupture. Initially, urgent transcatheter angiographic embolization of the cystic artery was performed to achieve hemodynamic stability. However, a triphasic computed tomography (CT) scan revealed the first attempt was unsuccessful, necessitating a second embolization. Subsequent imaging confirmed satisfactory embolization; however, a small area of liver necrosis was observed adjacent to the gallbladder. The patient was stable at discharge from the hospital and had an uncomplicated interval cholecystectomy. Discussion: This case highlights the complexity and challenges associated with diagnosing and managing cystic artery pseudoaneurysm rupture. Diagnosis often relies on arterial phase contrast-enhanced CT scan. While no guideline currently exist, management typically involves achieving hemodynamic stability through Transcatheter angiographic embolization, followed by interval cholecystectomy. Conclusion: Early recognition and intervention are crucial in managing cystic artery pseudoaneurysm rupture to prevent life-threatening haemorrhagic shock. Clinicians need to consider this rare condition in patients with upper GI bleeding and abnormal liver function tests.

Percutaneous thrombolysis via cholecystostomy catheter to dissolve biliary clots causing obstructive jaundice.

Haemobilia, or bleeding within the biliary tree, is rare. It can cause biliary obstruction secondary to blood clots. A comorbid 87-year-old was admitted to hospital with acute cholecystitis, choledocholithiasis, and an Escherichia coli bacteremia. He had a partial pancreatectomy and gastrojejunostomy 35 years prior for severe pancreatitis. He was treated with antibiotics and a percutaneous cholecystostomy. He developed atrial fibrillation and was subsequently commenced on warfarin. He re-presented 5 days after discharge with abdominal pain and fevers. Liver function tests revealed cholestasis and a supratherapeutic international normalised ratio. Imaging showed cholecystitis, biliary obstruction, and extensive biliary blood clots. He improved with antibiotics, vitamin K, and alteplase flushes through the percutaneous cholecystostomy. Repeat cholangiogram demonstrated dissolution of the biliary clots. Due to altered anatomy and comorbidities, alteplase flushes were utilized to relieve this patient's biliary obstruction. Thrombolytics may assist in treating biliary clots when first-line options are not possible or favourable.

Precordial pain caused by a hemocholecyst due to gallbladder cancer: A case report.

INTRODUCTION AND IMPORTANCE: A hemocholecyst refers to hemorrhage originating from and confined to the gallbladder. Intraluminal hemorrhage of the gallbladder is a rare symptom of gallbladder cancer (GBC), which can cause hemorrhagic cholecystitis. The symptoms of hemorrhagic cholecystitis are similar to those of classic acute cholecystitis where precordial pain is atypical. Here, we report a case of a precordial pain-inducing hemocholecyst due to GBC. CASE PRESENTATION: An 86-year-old woman was admitted to the emergency department due to persistent, sudden-onset precordial pain. Electrocardiogram (ECG) findings and cardiac enzyme levels were normal; however, severe anemia (hemoglobin 6.4 g/dL) was noted. Computed tomography (CT) showed a tense gallbladder with a heterogeneous, high-density area. Contrast-enhanced CT did not reveal contrast extravasation or obvious mass lesions. Considering the risk of hemorrhagic cholecystitis, we performed laparoscopic cholecystectomy. Operative findings were normal, however, the gallbladder lumen was filled with blood clots, while the gallbladder body had a papillary, infiltrating-type lesion. CLINICAL DISCUSSION: Histopathological examination confirmed the diagnosis of moderately differentiated gallbladder adenocarcinoma. The precordial pain disappeared postoperatively. Due to the patient's age and general condition, no additional gallbladder bed resection or S4/5 hepatic bisegmentectomy and lymphadenectomy were performed. CONCLUSION: A hemocholecyst can cause precordial pain; therefore, abdominal imaging may be useful for diagnosing patients with nonspecific precordial pain. In addition, GBC should be considered as a potential cause of hemocholecysts. Early diagnosis and urgent cholecystectomy should be performed to prevent gallbladder perforation in patients with hemocholecysts.

Porto-biliary fistula as an uncommon cause of haemobilia: A case report and literature review.

BACKGROUND: Haemobilia is a rare cause of gastrointestinal bleeding. It can be related to iatrogenic injuries, inflammatory diseases, and, more recently, postoperative, or post-procedure complications. Porto-biliary fistula is an uncommon case of haemobilia and has been related to iatrogenic injury or chronic inflammatory processes. To date, less than 30 cases of Porto-biliary fistula have been reported. CASE PRESENTATION: We present a 53 years-old woman with a history of biliary obstruction due to a choledochal cyst that required hepaticojejunostomy with evidence of anastomotic stricture. A percutaneous transhepatic biliary drainage (PTBD) was performed, with 3 failed attempts of percutaneous dilatation. A new hepaticojejunostomy was completed, however, 45 days later the patient presented to the emergency room with haemobilia and secondary hemodynamic instability. An emergency damage control laparotomy was performed, achieving bleeding control. In the second procedure, there is evidence of an ulcerative injury of the biliary tract secondary to a Porto-biliary fistula. CONCLUSION: Porto-biliary fistula is an entity that cannot be ruled out in cases of haemobilia, especially in cases with a history of bile duct surgical or percutaneous procedures. The prognosis is usually good if multidisciplinary management is performed, and the source of the bleeding is identified early.

Acute cholangitis due to haemobilia complicating percutaneous cholecystostomy: First literature case report.

BACKGROUND: Laparoscopic cholecystectomy is the standard treatment for acute cholecystitis. Cholecystostomy is a good option in patients with significant comorbidities. We report a case of a patient having had a percutaneous cholecystostomy for acute cholecystitis complicated with haemobilia and acute cholangitis. PRESENTATION OF A CASE: A woman aged 64 years old, with a history of diabetes, arterial hypertension, and chronic obstructive pulmonary disease was admitted to our institution with acute cholecystitis. We opted for transhepatic percutaneous cholecystostomy (PC) and antibiotics. On the fourth day, the patient had acute cholangitis due to haemobilia. We injected physiologic saline serum through the drain of cholecystostomy to dissolve the blood clot. There was a clinical improvement. We performed laparoscopic cholecystectomy two months later. The patient had an uneventful recovery with a follow-up of five months. DISCUSSION: We report the first literature report of acute cholangitis due to haemobilia complicating percutaneous cholecystostomy in a patient admitted for cholecystitis. We highlight the importance of the injection of saline physiologic serum from the catheter. Medical treatment with antibiotics may be enough knowing that blood clots can disappear spontaneously. In case of failure, ERCP with sphincterotomy should be performed. CONCLUSION: Haemobilia causing acute cholangitis is a rare complication of percutaneous cholecystostomy. Conservative treatment with antibiotics and injection of saline physiologic serum from the catheter is a good treatment option. In case of failure, ERCP should not be delayed.

Post-cholecystectomy Hepatic Artery Pseudoaneurysm Rupture.

Pseudoaneurysm of the hepatic and/or less frequently the cystic artery is a rare but potentially fatal complication following laparoscopic cholecystectomy. While the procedure is safe with minimal morbidity, complications do occur even in experienced hands. Moreover, patient selection is of utmost importance. These aneurysms usually present with hemobilia a few weeks after surgery; however, free rupture into the peritoneal cavity can occur. Transarterial embolization is the initial management approach when available and feasible. We present a case of a ruptured hepatic pseudoaneurysm three weeks after laparoscopic conversion to open cholecystectomy. The aim is to shed light on this rare but potentially fatal complication.

Symptomatic pseudoaneurysms following laparoscopic cholecystectomy: Focus on an unusual and dangerous complication.

BACKGROUND: Laparoscopic cholecystectomy (LC) has been associated with an increase in the incidence of biliary and vascular injuries. Pseudoaneurysms (PAs) following LC are rare life-threatening events with limited available experience regarding diagnosis and treatment. MATERIALS AND METHODS: An extensive review of literature during a 26-year period (1994-2020) using MEDLINE® database and Google Scholar® academic search engine revealed 134 patients with at least one symptomatic PA following LC. RESULTS: Nearly.81% of patients with PAs become symptomatic during the first 8 weeks following LC. The most common symptoms were gastrointestinal bleeding (74%) and abdominal pain (61%). In 28% of cases, there was a concomitant bile duct injury or leak from the cystic duct stump, whereas in about one-third of cases, PAs presented following an uneventful LC. The most common involved arteries were the right hepatic artery (70%), the cystic artery (19%) or both of them (3%). Trans-arterial embolisation was the favoured first-line treatment with a success rate of 83%. During a median follow-up of 9 months, the mortality rate was 7%. CONCLUSION: Clinicians should be aware of the PA occurrence following LC. Prompt diagnosis and treatment are essential.

A Case Report: Hepatic artery pseudoaneurysm causing life-threatening haemobilia.

INTRODUCTION & IMPORTANCE: Hepatic artery aneurysms (HAA) are rare and it accounts 20% of all visceral artery aneurysms. Commonly HAAs are autopsy findings, but rupture and bleeding carrying significant morbidity and can manifest as haemobilia. CASE PRESENTATION: A 63-year-old Sri Lankan male presented with severe melaena upper abdominal pain and features of obstructive jaundice was found to have a giant pseudoaneurysm at the right hepatic artery with the possible arterio-biliary fistula. The etiology for the pseudoaneurysm was not identified. Despite massive transfusion, the patient died before the endovascular intervention. CLINICAL DISCUSSION: Atherosclerosis is the leading cause of HAA formation but can be associated with connective tissue disorders and arteritis. Most of the HAA are asymptomatic. Aneurysms can be managed with surgical or endovascular interventions. CONCLUSION: Life-threatening haemobilia is a notorious complication of the rapture of HAA into the biliary system. The incidents of hepatic artery aneurysms and pseudoaneurysms due to percutaneous transhepatic interventions and minimal invasive hepatobiliary surgeries are in the rising trend. Nonleaking VAA can be best treated with endovascular treatment. The knowledge on this topic is important for the early detection and intervention of this rare entity.

Unsuccessful Stent Graft Repair of a Hepatic Artery Aneurysm Presenting with Haemobilia: Case Report and Comprehensive Literature Review.

AIMS: To discuss treatment strategies for non-traumatic, non-iatrogenic hepatic artery aneurysms (HAAs) in the presence of an arteriobiliary fistula, illustrated by a case and followed by a comprehensive review of the literature. METHODS: Following the PRISMA guidelines, 24 eligible HAA cases presenting with haemobilia were identified. Characteristics of patients, aneurysms, treatment strategies and their outcomes were collected. RESULTS: A 69 year old patient with no previous hepatobiliary intervention or trauma, presented with jaundice and haemobilia caused by a HAA. Initial treatment by endovascular stenting was chosen to prevent ischaemic liver complications. Unfortunately, this strategy failed because of stent migration due to ongoing infection leading to a type 1A endoleak. The patient had to be converted to open surgery with ligation of the HAA. The patient recovered uneventfully and no complications occurred during the following 12 months. COMPREHENSIVE LITERATURE REVIEW: Of the 24 cases, nine had a true HAA and 15 were pseudo/mycotic aneurysms, mainly caused by endocarditis or cholecystitis. The majority were located in the right hepatic artery. In 20 cases, an endovascular first approach was chosen with embolisation, none with covered stents. Three of these cases had to be converted to open surgery because of rebleeding. In all open (primary or secondary) cases, ligation of the HAA was performed. One patient in these series died. No liver ischaemia or abscesses were reported, although one patient developed an ischaemic gallbladder. CONCLUSIONS: Patients who present with a HAA and haemobilia may be treated safely by embolisation or open ligation. Using a covered stent graft in these patients can cause problems due to ongoing infection and should be monitored closely by imaging. Publication bias and lack of long term follow up imply cautious interpretation of these findings.

Endovascular treatment of a rare case of haemobilia caused by both pseudoaneurysm and a giant hepatic haemangioma.

Haemobilia is defined as bleeding from the biliary system due to abnormal communication between a blood vessel and the bile ducts. Melena or hematemesis, abdominal pain and jaundice represent the pathognomonic triad for haemobilia, but clinical presentation and aetiology of this entity are extremely variable. We report a case of a 50-year-old man with melena and anaemia and a clinical history of multivalvular endocarditis in which an extremely rare presence of 2 uncommon causes of haemobilia was found, such as a mycotic pseudoaneurysm and a giant hepatic haemangioma, both treated by transarterial embolization. In the management of haemobilia, TAE has been proven to be the treatment of choice because it combines a diagnostic angiography with therapeutic intervention in a minimally invasive, safe and effective way. Physician and radiologist should keep in mind also the uncommon aetiologies of haemobilia, knowing that the source of bleeding could be more than just one.

Hemobilia after laparoscopic cholecystectomy that was successfully treated conservatively: Case report.

INTRODUCTION: Hemobilia due to pseudoaneurysm rupture is a rare, life-threatening complication of laparoscopic cholecystectomy (LC) that can cause rapid hemodynamic instability. Therefore, symptoms of hemobilia must be assessed carefully. PRESENTATION OF CASE: An 88-year-old woman underwent LC in our hospital, and blood tests revealed elevation of hepatobiliary enzyme levels on postoperative day (POD) 12. Computed tomography (CT) showed a high absorption area in the common bile duct (CBD), and a diagnosis of hemobilia and a pseudoaneurysm without active bleeding into the abdominal cavity was made. There was no leakage of contrast medium outside the CBD during endoscopic retrograde cholangiography; thus, an endoscopic nasobiliary drainage (ENBD) tube was inserted on POD 12 and an endoscopic retrograde biliary drainage (ERBD) stent was placed in the CBD on POD 13. Thereafter, hepatobiliary enzyme levels gradually normalized and the ENBD tube and ERBD stent were removed on POD 27 and POD 54, respectively. The patient was discharged on POD 66. DISCUSSION: Hemostasis establishment using surgery or intervention radiology is often required for the treatment of hemobilia due to pseudoaneurysms; however, conservative treatment was effective in our case and we were able to pursue a minimally invasive approach. Erosion due to clip penetration or incomplete clipping of the cystic artery or its branches during surgery may have caused the cystic artery pseudoaneurysm. CONCLUSION: Hemobilia could be life threatening and cause acute hemodynamic instability; therefore, prompt diagnosis is required. Although the frequency of complication is low, the possibility of hemobilia after LC should be considered.

A pseudoaneurysm of the right hepatic artery treated successfully with a stent graft - A case report.

INTRODUCTION: Haemobilia caused by pseudoaneurysms of the right hepatic or cystic artery is rare. Haemobilia classically causes gastro-intestinal hemorrhage, jaundice and upper abdominal pain. PRESENTATION OF CASE: A 76-year old female underwent laparoscopic cholecystectomy because of a severe acute on chronic cholecystitis. A massive arterial bleeding occurred during surgery, which was controlled with hemoclips. Approximately one week after surgery the patient developed severe colic pains and cholestatic liver enzyme alterations. Endo-ultrasound showed normal-width bile ducts, however during a subsequent ERCP haemobilia was observed. On computed tomography a pseudoaneurysm of the right hepatic artery was seen. Selective embolization was initially successful, however, a rebleed was observed two weeks later and a 6 × 50 mm Viabahn stent graft was placed in the right hepatic artery uneventfully. The patient remained free of complaints during 3-years of follow-up. DISCUSSION: Pseudoaneurysms of the cystic or hepatic arteries are described to be cholecystectomy or cholecystitis related. The etiology of the pseudoaneurysm in this case can be inflammatory or iatrogenic. Embolization is the golden standard in pseudoaneurysm treatment. Stent graft implantation has not been frequently described as an alternative option to surgery after a failed attempt of embolization. CONCLUSION: This case report presents a probable cholecystitis related pseudoaneurysm of the right hepatic artery, which caused haemobilia after cholecystectomy. The pseudoaneurysm was successfully eliminated with a stent graft after embolization had failed. Stent grafts should be considered a minimal invasive and effective alternative after failed embolization of a pseudoaneurysm.

Haemobilia Secondary to Spontaneous Cystic Artery-Gallbladder Fistula: A Unique Gastrointestinal Anomaly.

Spontaneous cystic artery-gallbladder fistula is an extremely rare condition described in the medical literature. We have found two articles in the literature describing fistula formation between the cystic artery and gall bladder. In this report, we present a unique case of a cystic artery-gall bladder fistula that resulted in massive gastrointestinal bleeding through cystic artery erosion and was adequately managed with coil embolization.

Haemobilia: secondary to micro aneurysms of hepatic artery.

Hepatic artery is the fourth most common site of the intraabdominal aneurysm, after infra renal aorta, iliac artery and splenic artery aneurysms. Rupture of the aneurysm may lead to the upper gastrointestinal haemorrhage. Here we report a 5 years old boy, who presented with fever, abdominal distension and unexplained upper GI bleed. Upper GI endoscopy revealed a normal esophagus and stomach with clear evidence of haemobilia with blood oozing from the ampulla. Fluoro- guided angiography followed by embolization of hepatic artery branches with 5 metallic coils was performed in this case by an interventional radiologist.

Haemobilia in a previously stented hilar cholangiocarcinoma: successful haemostasis after the insertion of fcSEMS.

Haemobilia describes blood loss from the biliary tract and classically presents as Quincke's triad: upper gastrointestinal bleeding (UGIB), jaundice and right upper quadrant abdominal pain. We discuss the case of a 70-year-old male with a previously stented Bismuth 1 hilar cholangiocarcinoma who presented with haematemesis. He had a similar presentation a month ago where a forward viewing gastroscope identified fresh and altered blood in the distal stomach but no clear source of bleeding. During this admission, a side-viewing duodenoscope identified bleeding from the periampullary region, which was managed by inserting a fully covered self-expanding metal stent (fcSEMS) within his pre-existing uncovered SEMS to tamponade the haemorrhage. This case highlights the importance of using a side-viewing duodenoscope for patients with UGIB on a background of a stented cholangiocarcinoma and inserting a fcSEMS within an uncovered SEMS is feasible and effective in managing these patients.

Early-stage T1b adenocarcinoma arising in the remnant cystic duct after laparoscopic cholecystectomy: a case report and literature review.

BACKGROUND: The cystic duct has been included in the staging classification scheme for gallbladder cancer since the 2010 publication of the AJCC Cancer Staging Manual (7th edition). To our knowledge, only seven other cases of adenocarcinoma arising in the remnant cystic duct following cholecystectomy have been reported in the English-language literature, and none has been reported as primary early-stage T1b remnant cystic duct cancer (CDC). We report, herein, a case of primary adenocarcinoma arising in the remnant cystic duct in a patient with history of laparoscopic cholecystectomy for gallstone disease. CASE PRESENTATION: An 81-year-old female presented with abdominal pain. Her medical history included a laparoscopic cholecystectomy for cholecystolithiasis two years prior. Jaundice was observed; imaging studies suggested that this was caused by choledocholithiasis. Blood chemistry findings showed severe liver dysfunction. Endoscopic retrograde cholangiography revealed haemobilia from the common bile duct with no evidence of choledocholithiasis. A bile sample showed Papanicolaou class IV cytology. As the extent of tumour spread was undetermined by abdominal ultrasonography and endoscopic ultrasonography, peroral cholangioscopy (POCS) was performed, which revealed tiny papillary lesions within the confluence of cystic duct, and fine granular lesions in the centre of bile ducts, signifying early-stage remnant CDC. Extrahepatic bile duct resection with regional lymphadenectomy was done. Histopathological findings revealed a 42-mm tubular adenocarcinoma originating from the remnant cystic duct with the considerable shallow spread across the extrahepatic bile ducts. It invaded the fibromuscular layer, with no lymphovascular or perineural invasion, no lymph node metastasis (13 nodes examined), and uninvolved surgical resection margin (R0 resection), and was staged as pT1bN0M0, Stage I. CONCLUSIONS: Primary early-stage T1b remnant CDC is an uncommon condition for which early diagnosis is challenging; if intraoperatively recognized, it can complicate surgery. Our experience of this case and an overview of the English literature suggest that POCS is an efficient tool to diagnosis this tumour and assess its spread along the extrahepatic bile ducts.

Portal vein pseudoaneurysm secondary to pancreatic lymphoma and biliary stent insertion: a rare cause of haemobilia.

BACKGROUND: Haemobilia, defined as bleeding from the biliary tree, is a rare entity. The most common cause of haemobilia is iatrogenic trauma, which accounts for 70% of cases. Pseudoaneurysms of the portal vein are an extremely rare cause of haemobilia with only four reported cases to date. Conservative treatment, open surgical repair and percutaneous trans hepatic stent-grafting have all been employed in these cases. This displays the lack of consensus regarding the treatment of this condition.We report the first case of a portal vein pseudoaneurysm following endoscopic common bile duct stent placement performed to relieve obstruction of the common bile duct for lymphomatous infiltration of the pancreatic head. The pseudoaneurysm was successfully treated by placement of a percutaneous trans hepatic covered stent-graft. CASE PRESENTATION: A 42-year-old man with a history of lymphomatous infiltration of the pancreatic head and recent endoscopic common bile duct stent placement presented with sudden onset large volume haematemesis. On the portal venous phase of a triple phase CT, this was found to be secondary to a portal vein pseudoaneurysm bulging into the upper portion of the indwelling biliary stent. The pseudoaneurysm was successfully treated by percutaneous trans hepatic placement of a covered vascular stent-graft. CONCLUSIONS: We report a rare case of portal vein pseudo aneurysm successfully treated by percutaneous trans hepatic portal venous covered vascular stent-graft insertion.

A case report of bloody pancreatitis.

INTRODUCTION: Haemobilia is an uncommon entity even though its frequency has increased with hepato-biliary instrumentation and procedures. It can be associated with obstructive jaundice and pancreatitis (Green et al., 2001) [1]. Haemobilia following cholecystectomy has frequently been reported in association with hepatic artery pseudo-aneurysm (Curet et al., 1981; Ribeiro et al., 1998) [2,3]. The authors wish to report a case of haemobilia due to a porto-biliary fistula presenting as acute pancreatitis. PRESENTATION OF CASE: A 34-year-old female admitted as an urgency with upper abdominal pain for 3 weeks. She had, in the preceding days, been admitted to another hospital with acute pancreatitis. She reported an episode of rectal bleeding during that admission and possessed an abdominal ultrasound scan (USS) and magnetic resonance cholangiopancreatography (MRCP) which suggested the presence of a biliary tract neoplasm. The patient was also found to be jaundiced and the diagnosis of a porto-biliary fistula was made at operation. CONCLUSION: The diagnosis in this case was found to be a portal vein-biliary tract fistula occurring post cholecystectomy. An awareness of the spectrum of complications related to modern surgical techniques may aid timely diagnosis and the achievement of favourable outcomes.

Ascending Cholangitis secondary to migrated embolization coil of gastroduodenal artery pseudo-aneurysm a case report.

BACKGROUND: Gastroduodenalartery (GDA) pseudo-aneurysms are very rare. Their clinical importance lies in the eventuality of rupture, causing bleeding and ultimately exsanguination. CASE PRESENTATION: We report the case of a man, with prior history of biliary surgery, presenting with haemobilia secondary to a rupture of GDA pseudo-aneurysm eroding the main bile duct. The patient was treated with coil embolization. This technique is considered to be safe. However, on the long term, some complications may occur. In our case, the patient presented with cholangitis subsequent to coil migration in the lower bile duct. This situation was managed using endoscopic retrograde cholangiopancreatography (ERCP) allowing coil extraction with favorable evolution. CONCLUSIONS: GDA pseudo-aneurysms are very rare. Bleeding, secondary to the rupture of these lesions, is a serious complication that could lead to death. Diagnosis and treatment of ruptured GDA pseudo-aneurysms rely on angiography. This method is considered to be safe. Cholangitis secondary to coil migration in the main bile duct is exceedingly rare,but remains an eventuality that physicians should be cognizant of.