S1581 Hemobilia From an Unlikely Culprit: A Case of a Ruptured Pseudoaneurysm

Abstract

Introduction: Hemobilia, or bleeding from the hepatobiliary tract, is a rare cause of GI bleeding and jaundice. Most cases of hemobilia are iatrogenic secondary to hepatobiliary interventions, however, trauma and malignancy also represent a major source. We present a case of hemobilia secondary to a hepatic artery pseudoaneurysm, in the setting of acute cholecystitis and metastatic liver disease. Case Description/Methods: A 67-year-old man presented with 3 days of RUQ abdominal pain radiating to the epigastrium. On arrival, he was tachycardic, afebrile, and normotensive. He had RUQ tenderness and icterus. Laboratory findings were significant for leukocytosis, anemia, transaminitis, elevated alkaline phosphatase, and hyperbilirubinemia. An ultrasound of the abdomen was suggestive of calculous cholecystitis and a dilated CBD of 0.8 cm. He underwent a EUS which revealed a dilated CBD with heterogeneous mater. An ERCP showed altered blood at the ampulla. A sphincterotomy was performed and a large blood clot was extracted from the CBD via balloon sweeps. Two plastic stents were then placed for drainage after which brisk arterial bleeding was noted. Urgent angiography revealed evidence of a ruptured pseudoaneurysm arising from the anterior division of the right hepatic artery near segment 8 of the liver. Successful coil embolization was performed. A CT scan of the abdomen revealed rectal thickening and hypoenhancing liver lesions suggestive of metastatic disease. On flexible sigmoidoscopy, a fungating, partially obstructing rectal mass was seen, biopsies of which were positive for invasive adenocarcinoma. Cholecystitis confirmed on HIDA scan was treated conservatively with antibiotics. He was subsequently discharged and started on chemotherapy as an outpatient. He is now planned for a repeat ERCP with stent exchange. Discussion: Hemobilia can masquerade as biliary stones on EUS. Management includes early diagnosis, identification of the source of bleeding, achieving hemostasis, and relieving the obstruction. Transcatheter arterial embolization is preferred if there are any signs of arterial extravasation. Biliary obstruction can be relieved with ERCP and stent placement. In the presence of underlying malignancy, infiltrative disease and its surrounding vascular friability are often implicated. However, a benign etiology should not be overlooked as illustrated in our case. Cholecystitis leading to severe inflammation of the gallbladder bed can cause adjacent arterial wall degeneration and pseudoaneurysm formation.Figure 1.: (A) Superselective catheterization of the right hepatic artery and angiography demonstrating evidence of 1.2 x 0.9 cm pseudoaneurysm/contained perforation, arising from a suspected proximal segment 8 arterial branch. (B) Endoscopic ultrasound demonstrating a dilated common bile duct up to 12 mm, filled with heterogeneous material. The gallbladder wall appears thickened. (C) CT abdomen with contrast showing multiple hypoenhancing liver lesions within the right and left lobes. Surgical coils within the right lobe of the liver consistent with a recent embolization procedure. Common bile duct stent in place, and small foci of pneumobilia. (D) ERCP images showing blood clots protruding from the ampulla. After balloon sweeps and sphincterotomy, two 10 Fr by 7 cm plastic stents were placed in the CBD.Table 1.: Laboratory Values from Admission and Discharge day.