Cystic Artery Pseudoaneurysm: A Rare Cause of Massive GI Bleed

Abstract

Purpose: A 33-yr-old AA man presented to the EC with nausea and vomiting blood clots that started 12 hrs prior. He had a medical history of HIV and choledocholithiasis for which he had an ERCP with sphincterotomy and laparoscopic cholecystectomy two months prior to admission. His hemoglobin was 5.9 g/dl on arrival. He had significant right upper quadrant abdominal pain. He was admitted to the medical ICU and the GI service was consulted. An initial EGD revealed no source of bleeding, there was blood in the second portion of the duodenum but no active bleeding from the previous sphincterotomy. An ERCP was planned, however, prior to the procedure the patient had massive hematemesis and became hemodynamically unstable necessitating an emergent mesenteric angiography in interventional radiology. Superior mesenteric, inferior mesenteric and celiac axis arteriograms were performed and showed gross extravasation at the region of the stump of the cystic artery. This was successfully embolized and a subsequent angiogram showed no more extravasation. He had no more episodes of bleeding and he was discharged home. Cystic artery pseudoaneurysm which develops 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 is 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 extravasation 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. We present this case of a massive gastrointestinal bleed to highlight the rare entity of cystic artery pseudoaneurysm. Explicit knowledge of the patients past surgical history and a high index of suspicion are needed to successfully diagnose and treat this often life threatening condition. An initial endoscopic evaluation is warranted and if no source is identified than selective arteriography followed then by embolization is the next modality of choice. High index of suspicion and swift transition from endoscopy to angiography has been shown to reduce mortality and morbidity as demonstrated by our case.