S1396 Intraluminal Cystic Artery Pseudoaneurysm Manifesting With Hemobilia

Abstract

INTRODUCTION: Cystic artery pseudoaneurysm (CAP) is a rare cause of hemobilia and may arise as sequelae of inflammatory processes such as acute cholecystitis or surgical/procedural interventions. Its pathogenesis is posited to be due to vascular wall erosion from surrounding inflammation or, in the case of iatrogenic injury, direct vascular injury. We present a rare case of CAP arising after percutaneous cholecystostomy placement and a subsequent fall. CASE DESCRIPTION/METHODS: An 80-year-old woman with atrial fibrillation and recurrent pulmonary embolism was admitted to the hospital with acute cholecystitis. She was treated with IV antibiotics and percutaneous cholecystostomy. 5 days after cholecystostomy, the patient suffered from a fall and complained of RUQ abdominal pain and hematemesis the next day. Vitals were normal and her her abdomen was soft with RUQ tenderness. Cholecystostomy drainage bag had almost 400 mL of bloody output. Hemobilia was suspected due to the combination of bloody cholecystostomy output and hematemesis. CT abdomen demonstrated heterogeneously dense fluid (50 to 70 Hounsfield units) within the gallbladder lumen, concerning for hemorrhagic blood products, and a new cystic artery pseudoaneurysm measuring 6 mm [Figure 1]. The patient developed obstructive jaundice one day later with total bilirubin 3.8 mg/dL, direct bilirubin 3.1 mg/dL, alkaline phosphatase 635 U/L, GGT 740 U/L, AST 354 U/L, ALT 114 U/L highly suggestive of hemobilia (Quincke’s triad of obstructive jaundice, abdominal pain and GI bleeding). Repeat CT abdomen showed the cystic artery pseudoaneurysm now 1.3 centimeters [Figure 2]. Cholecystectomy with resection of the pseudoaneurysm was performed without complication. DISCUSSION: Diagnosis of cystic artery pseudoaneurysm should be considered in patients with antecedent biliary tract intervention or inflammation presenting with hemobilia. Contrast enhanced computed tomography may visualize a nodular lesion associated with the cystic artery with the same degree of enhancement as the aorta. Conventional angiography may be utilized in cases where transcatheter arterial embolism is planned and offers visualization of the pseudoaneurysm in real time. Management of cystic artery pseudoaneurysm is contingent on a patient’s clinical condition. In stable patients, cholecystectomy with surgical ligation reflects definitive management. Arterial embolization with delayed cholecystectomy may be preferred in cases of hemodynamic instability or contraindications to surgical management.Figure 1.: CT abdomen (day 9) re-demonstrating pericholecystic inflammatory changes consistent with known cholecystitis, interval development of hemorrhagic blood within gallbladder lumen, and cystic artery pseudoaneurysm measuring 6 mm (red arrow).Figure 2.: CT abdomen (day 11) axial view (A) and sagittal view (B) demonstrating interval increase in blood products within the gallbladder lumen and increased size of cystic artery pseudoaneurysm to 1.3 centimeters (red arrows).