Aberrant Right Hepatic Artery Leading to Duodenal Obstruction

Abstract

A 60-year-old male presented with 1 day of epigastric abdominal pain and vomiting. His medical history included type II diabetes and hypertension. He underwent a weight loss of approximately 45 pounds in five months to better control his diabetes. General physical examination revealed diffuse tenderness and distention of the abdomen without peritoneal signs. Complete blood count and basic metabolic panel results were normal. An abdominal radiograph showed marked gastric distention with air-fluid levels in the stomach and proximal duodenum (Fig. 1). Computed tomography angiogram of the abdomen showed an aberrant right hepatic artery (ARHA) causing proximal duodenal obstruction (Fig. 2). The patient's clinical condition improved with nasogastric drainage and he was subsequently discharged the day after admission. He consulted with a vascular surgeon one week after discharge. The vascular supply to the liver consists of the hepatic portal vein and hepatic artery. Within 77% of the population the hepatic artery branches from the celiac artery to supply the liver; however, aberrant hepatic arterial anatomy is quite common. Studies have shown greater than 41% of the population posses anomalies of which 13-26% have anomalies in the origin of their right hepatic artery. Despite its frequency ARHAs are generally encountered during pancreaticoduodenectomy and have not been associated with intestinal obstruction. The condition is also encountered in liver transplant (15% of donor livers). ARHA can arise from the superior mesenteric artery in 11.6% of patients. This case presents an ARHA originating from the superior mesenteric artery that encircled the second portion of the duodenum and led to compression after a rapid weight loss by the patient. The main importance is recognition by the radiologist and surgical consultation to prevent ligation of the aberrant artery or biliary duct which can lead to ischemia. The patient opted for conservative management as an outpatient but was offered vascular input versus a surgical Biliroth II procedure.2584_A Figure 1. Moderate gastric distention with multiple air-fluid levels seen in the stomach and proximal duodenum on abdominal radiograph.2584_B Figure 2. An aberrant right hepatic artery causing obstruction of the proximal duodenum on computed tomography angiogram of the abdomen.