Upper Gastrointestinal Bleeding from A Post-traumatic Pseudoaneurysm of the Right Hepatic Artery: Think Outside the Box

Abstract

Purpose: Case: A 68-year old male with a past medical history of alcohol abuse presented to the ED as a pedestrian involved in a motor vehicle accident. He had stable basal skull fractures, stable vertebral fractures, multiple right rib fractures with associated pulmonary contusions, and stable liver lacerations without bleeding. He was intubated and mechanically ventilated secondary to respiratory failure from his lung and chest wall injuries. His laboratory workup initially showed elevated liver enzymes, but was otherwise unremarkable. He was admitted to the surgical intensive care unit and developed maroon colored stools with a 3-gram drop in his hemoglobin. An upper endoscopy was performed and showed a non-bleeding visible vessel at the gastro-esophageal junction (GEJ) that was clipped with no further bleeding noted, normal stomach, and unremarkable duodenum with bile present up to the second portion of duodenum. A colonoscopy showed maroon colored stool in the colon with diffuse diverticulosis but no source of active bleeding was identified. In the interim, the patient continued to have obscure, overt bleeding and was not adequately responsive to red blood cell transfusion. His bilirubin and alkaline phosphatase were rising, and he had fresh episodes of coffee ground aspirates from his orogastric tube. A repeat upper endoscopy was performed which showed a small area of gastric erosion, an intact endoclip at the GEJ, and blood with blood clots throughout the stomach into the second portion of the duodenum. No source of bleeding was identified to explain the patient's persistent upper GI bleeding. In the view of his recent liver injuries, a duodenoscope was used to examine the ampulla to exclude hemobilia. A blood clot was seen protruding from the ampulla of vater. A recommendation was made to obtain an angiogram to exclude an active source of bleeding. Angiogram of the celiac artery showed a 2x1 cm pseudoaneurysm of the right hepatic artery (RHA) within the right inferior lobe of the liver. Successful coil embolization of the RHA was done with good post angiographic results. Conclusion: We present a unique case of RHA pseudoaneurysm causing hemobilia and upper GI bleeding. There are few reports of hepatic artery pseudoaneurysm as a delayed complication of blunt abdominal trauma. Continued signs of UGI bleeding in a setting of abdominal injury should raise the suspicion of hemobilia and possible hepatic artery injury. The use of a duodenoscope in these situations has great benefit in establishing an accurate diagnosis.