1919 Hemobilia Due to Cystic Artery Pseudoaneurysm: A Rare Cause of Hematemesis in a Pediatric Patient With Obstructive Jaundice

Abstract

INTRODUCTION: Hemobilia is a rare cause of upper gastrointestinal (GI) bleeding, especially within the pediatric population. Here we present a case of hematemesis initially presumed to be secondary to a Mallory-Weiss tear in the setting of choledocholithiasis and later found to have hemobilia due to cystic artery pseudoaneurysm. The triad of right upper quadrant abdominal pain, obstructive jaundice and upper gastrointestinal bleed should prompt consideration of hemobilia. CASE DESCRIPTION/METHODS: A 16 year old male with history of obesity and gastroesophageal reflux disease presented to the emergency department with severe epigastric pain and hematemesis. Labs were notable for elevated transaminases [AST 347 (U/L), ALT 422 (U/L)] and conjugated hyperbilirubinemia [direct bilirubin 2.6 (mg/dL), indirect bilirubin 0.3 (mg/dL)]. Abdominal ultrasound showed a large gallstone with a dilated common bile duct (CBD) dilation (1.1 cm). MRCP was negative for filling defects, but showed mild central intrahepatic and extrahepatic ductal dilation with a large gallstone and debris filling the gallbladder lumen. An EGD was performed and a superficial ulcer was seen in the duodenal bulb and presumed to be the source of bleeding. Due to persistence of hematemesis, transaminitis, and up trending GGT 585 (U/L) and direct bilirubin 3.7 (mg/dL), there was question of a distal CBD obstruction. An ERCP was performed, and fresh blood clots were coming from the ampulla. A cholangiogram showed multiple filling defects in the common bile duct from blood clots. Sphincterotomy and CBD stent placement were then performed. Abdominal CT angiography showed a focal arterial density collection along the posteromedial gallbladder mucosal surface, consistent with a pseudoaneurysm vs vascular malformation. A visceral angiogram demonstrated a pseudoaneurysm arising from the posteromedial wall of the cystic artery with successful cystic artery coil embolization. A laparoscopic cholecystectomy was attempted, but was converted to an open surgery, which removed the gallbladder and a large gallstone. He had an unremarkable recovery. DISCUSSION: Hemobilia is an uncommon cause of upper GI bleeding within the pediatric population. Most commonly hemobilia is the result of trauma or iatrogenic from hepatobiliary procedures. Angioembolization is often indicated and followed immediately with surgery. In summary, the triad of right upper quadrant abdominal pain, biliary obstruction and upper gastrointestinal bleed should prompt consideration of hemobilia.