Hemobilia Due to Hepatic Artery Pseudoaneurysm˙ An Unusual Complication after Cholecystectomy and T-Tube Placement

Abstract

Hemobilia is one of the causes of obscure gastrointestinal hemorrhage. Arterio-biliary fistula secondary to hepatic artery pseudoaneurysm is an uncommon cause of hemobilia. Hepatic artery pseudoaneurysm has been reported as a rare complication of laparoscopic cholecystectomy. We here report a case of hemobilia due to arterio-biliary fistula in a patient one month after cholecystecomy and percutaneous T-tube placement. A 54 year old woman underwent laparoscopic cholecystectomy for symptomatic cholelithiasis. During the procedure, there was a concern of injury to the common hepatic duct due to difficult gall bladder dissection. Laparoscopic cholecystectomy was converted to an open cholecystectomy which did show common hepatic duct laceration which was repaired and a T-tube was placed. Patient did well for a month after the surgery, when she developed right upper quadrant abdominal pain, jaundice and noted to have migrated out T-tube. Subsequently, T-tube was removed due to malfunction. A computed tomography scan of the abdomen showed dilation of the intra and extra hepatic biliary ducts. Patient underwent endoscopic retrograde cholangiography (ERC) and found to have gross hemobilia. ERC images showed dilated common bile duct with multiple cast-like filling defects, consistent with blood clots. A biliary stent was placed to maintain biliary drainage. Patient continued to require blood transfusions due to ongoing hemobilia. A selective hepatic arteriogram showed hepatic artery pseudo-aneurysm causing arterio-biliary fistula leading to hemobilia. A covered stent was placed in the right hepatic artery occluding the fistula, which resulted in complete resolution of bleeding.