Hepatic Artery Pseudoaneurysm: A Unique Cause of Obscure Upper GI Bleeding

Abstract

Hepatic Artery Pseudoaneurysm (HAP) is a rare clinical entity and is usually associated with iatrogenic or traumatic etiologies, and almost always manifests with hemobilia. We report the first documented case of HAP in a patient with chronic cholecystitis without any underlying history of trauma or surgery, presenting as massive upper gastrointestinal hemorrhage (UGIH) without hemobilia. A 73 year old Caucasian female with past history of NIDDM, hypertension, hyperlipidemia presented to ER with non-radiating epigastric pain, nausea and black melanonic stools for past 24 hours. Pertinent labs on admission showed a Hb of 10.3 g, WBC 12.3, T.B 2.3 mg, AST 525 U, ALT 451 U, ALP 133 U, BUN 35 and S.Cr 1.0. Abdominal ultrasound showed multiple gallstones, and the CT scan showed a large intraluminal echogenic structure consistent with a gallstone, with thickened GB wall. Over the next day, the patients Hb dropped to 6 g and upper GI Endoscopy (UGIE) revealed acute hemorrhage, possibility of a duodenal ulcer was entertained. To investigate the possibility of GB malignancy in view of the above radiological findings and CA 19–9 level of 2801, an ERCP was done which showed no hemobilia or stone, and a CBD stent was placed for patency. Patient continued to have UGIH with falling Hb, and multiple endoscopies failed to achieve adequate hemostasis. Subsequent UGIE study showed an adherent clot on the lateral wall with active oozing. Patient was then taken for selective catherization and angiogram of the celiac trunk and right hepatic arteries, which yielded visualization of large extravasations of contrast from the inferior aspect of the right common hepatic artery and confirmed a pseudoaneurysm, eroding into the duodenal mucosa. Successful embolization and hemostasis was achieved. The patient also had a gall bladder biopsy to rule out malignancy, which revealed chronic active cholecystitis. This case illustrates a extremely rare association of HAP with chronic cholecystitis presenting as UGIH in an unusual form and not as the classical hemobilia. Of the multiple case reports and series submitted for HAP, almost all have shown a preceding interventional procedure involving the hepatobiliary and pancreatic systems or history of trauma. HAP due to biliary inflammation is usually attributed to stone eroding into the artery or due to local weakness of vessel wall. Awareness of this rare presentation and association of HAP may allow early diagnosis and timely intervention.