A Bloody Connection: A Case of Hepatic Artery Pseudo Aneurysm Presenting as Hematemesis

Abstract

Hemobilia is bleeding from biliary tree. It is a rare un-predictable jeopardizing vascular complication that is usually iatrogenic. Other causes include choledochelithiasis, biliary parasites, choledochal varices and biliary tumors. Upper gastrointestinal (GI) bleeding with melena is the most common presentation, followed by abdominal pain and jaundice (Quincke's triad). This triad is present in only 22% of cases. Our patient is a 66-year-old male with past history significant for Hepatitis C related end stage liver disease complicated by hepatocellular carcinoma. He underwent orthotropic liver transplant and he developed elevated liver transaminases postoperatively. Imaging revealed a 13-cm sub capsular collection due to anastomotic bile leak. This was managed initially by placement of a percutaneous biliary drain followed by endoscopic biliary sphincterotomy and 10F bile duct stenting (Figure-1) adjacent to the 6F stent across the anastomosis deployed at surgery. Liver enzymes continued to rise despite adequate biliary drainage and subsequent liver biopsy showed periductular neutrophilic infiltrate consistent with acute cholangitis. Three weeks later, patient suffered an episode of hematemesis of 500 cc of fresh blood. An emergent endoscopy visualized large blood clot in the stomach and oozing of fresh blood from the ampulla of Vater. Prior surgically deployed stent was removed during EGD using rat tooth forceps. CT angiogram revealed a 2-cm PA of the transplanted hepatic artery abutting the bile duct with stent forming a fistula resulting in hemobilia (figure-2). Immediate angiography (figure-3) was performed and a hepatic arterial stent was deployed occluding the PA with prompt cessation of further bleeding. A follow up magnetic resonance cholangiopancreatography confirmed intact CBD and absence of leakage from biliary tree. Hepatic artery dissection and PA, although rare after liver transplantation, can be fatal with mortality reported to be as high as 69%. A high index of suspicion is always required for diagnosis. It's believed that an injury to hepatic artery during liver biopsy is the insult causing PA formation. Although literature was scant on utility of stenting of hepatic PA during acute hemorrhage, our patient responded well to this minimally invasive approach. This report highlights the importance of considering hepatic artery PA, albeit rare, as a cause of hemobilia in those undergoing liver biopsy after liver transplantation.Figure: Blood clot at the ampulla (arrow) along with biliary stents in situ.Figure: A 2-cm PA (red arrow) of the transplanted hepatic artery abutting the bile duct with stent (blue arrow) forming a fistula.Figure: Appearance of PA (red arrow) before stent placement followed by stenting of common hepatic artery PA under fluoroscopic guidance (blue arrow).