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Therapeutic considerations in obstructive jaundice due to hepatic artery aneurysm
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Letters to the editor
Therapeutic considerations in obstructive jaundice due to hepatic artery aneurysm
D.M. SHELDON, M. CRAWFORD, S. MIHRSHAHI, J. GALLAGHER & D. STOREY Department of Hepato-Biliary Upper GIT Surgery, Royal Prince Alfred Hospital, Sydney, Australia
Sir, The presentation of a 52-year-old woman with obstructive jaundice and an aneurysm of the common hepatic artery prompted analysis of the relative merits of surgery compared to interventional radiology in her case. The aneurysm was a true fusiform aneurysm of the common hepatic artery, presumed to be mycotic, as she had undergone a mitral valve replacement 2 years previously for bacterial endocarditis. Hepatic artery aneurysms may present as Quinke’s triad of abdominal pain, haemobilia and obstructive jaundice [1]. However 60 /80% of patients present when the aneurysm ruptures. Jaundice may occur by external compression of or rupture into the biliary tree with thrombotic debris occluding the lumen. An endoluminal stent had relieved her jaundice. A selective angiogram demonstrated the aneurysm and showed occlusion of the right hepatic artery. Significant collateral circulation was present, indicating that hepatic artery occlusion could be tolerated without ischaemic hepatic injury. Ligation of the common hepatic artery with excision of the aneurysm and ligation of its branches was performed. The aneurysm had actually destroyed the left side of the common hepatic duct and frank rupture into the bile duct was only prevented by the thrombus within the lumen of the aneurysm. The aneurysm and the damaged hepatic duct and gallbladder (containing stones) were resected and an
hepatodocho-jejunostomy reconstruction was performed. Hepatic arterial perfusion remained adequate and no arterial reconstruction was required. Once jaundice develops in the presence of hepatic artery aneurysm frank rupture may have already occurred or should be considered imminent. Embolization may prevent or control haemorrhage [2]. However, as the bile duct may be extensively damaged and as the aneurysmal thrombosis may be infected, surgical treatment would appear to be the preferred definitive treatment rather than embolization. The development of jaundice in a case of hepatic artery aneurysm should prompt urgent surgical intervention. Although insertion of an endoluminal stent successfully relieved the biliary obstruction prior to this patient’s referral to our unit we would caution against stenting. The risk of a stent entering the aneurysm and precipitating major haemorrhage must be considerable. The biliary obstruction should be dealt with as part of the definitive excision of the aneurysm and repair of the damaged bile duct.
References [1] Harlafis NN, Akin JT. Haemobilia from ruptured hepatic artery aneurysm. Am J Surg 1977;133:229 /32. [2] O’Connor PJ, Chalmers AG, Chennells PM, Lintott DJ. The radiological treatment of hepatic artery aneurysms. Clin Radiol 1995;50:792 /6. /
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Correspondence: D.M. Sheldon, RPAH Medical Centre, 100 Carillon Avenue, Newtown NSW 2042, Australia. E-mail: [email protected]
ISSN 1365-182X print/ISSN 1477-2574 online # 2006 Taylor & Francis DOI: 10.1080/13651820500472804
Letters to the editor
Therapeutic considerations in obstructive jaundice due to hepatic artery aneurysm
D.M. SHELDON, M. CRAWFORD, S. MIHRSHAHI, J. GALLAGHER & D. STOREY Department of Hepato-Biliary Upper GIT Surgery, Royal Prince Alfred Hospital, Sydney, Australia
Sir, The presentation of a 52-year-old woman with obstructive jaundice and an aneurysm of the common hepatic artery prompted analysis of the relative merits of surgery compared to interventional radiology in her case. The aneurysm was a true fusiform aneurysm of the common hepatic artery, presumed to be mycotic, as she had undergone a mitral valve replacement 2 years previously for bacterial endocarditis. Hepatic artery aneurysms may present as Quinke’s triad of abdominal pain, haemobilia and obstructive jaundice [1]. However 60 /80% of patients present when the aneurysm ruptures. Jaundice may occur by external compression of or rupture into the biliary tree with thrombotic debris occluding the lumen. An endoluminal stent had relieved her jaundice. A selective angiogram demonstrated the aneurysm and showed occlusion of the right hepatic artery. Significant collateral circulation was present, indicating that hepatic artery occlusion could be tolerated without ischaemic hepatic injury. Ligation of the common hepatic artery with excision of the aneurysm and ligation of its branches was performed. The aneurysm had actually destroyed the left side of the common hepatic duct and frank rupture into the bile duct was only prevented by the thrombus within the lumen of the aneurysm. The aneurysm and the damaged hepatic duct and gallbladder (containing stones) were resected and an
hepatodocho-jejunostomy reconstruction was performed. Hepatic arterial perfusion remained adequate and no arterial reconstruction was required. Once jaundice develops in the presence of hepatic artery aneurysm frank rupture may have already occurred or should be considered imminent. Embolization may prevent or control haemorrhage [2]. However, as the bile duct may be extensively damaged and as the aneurysmal thrombosis may be infected, surgical treatment would appear to be the preferred definitive treatment rather than embolization. The development of jaundice in a case of hepatic artery aneurysm should prompt urgent surgical intervention. Although insertion of an endoluminal stent successfully relieved the biliary obstruction prior to this patient’s referral to our unit we would caution against stenting. The risk of a stent entering the aneurysm and precipitating major haemorrhage must be considerable. The biliary obstruction should be dealt with as part of the definitive excision of the aneurysm and repair of the damaged bile duct.
References [1] Harlafis NN, Akin JT. Haemobilia from ruptured hepatic artery aneurysm. Am J Surg 1977;133:229 /32. [2] O’Connor PJ, Chalmers AG, Chennells PM, Lintott DJ. The radiological treatment of hepatic artery aneurysms. Clin Radiol 1995;50:792 /6. /
/
/
/
Correspondence: D.M. Sheldon, RPAH Medical Centre, 100 Carillon Avenue, Newtown NSW 2042, Australia. E-mail: [email protected]
ISSN 1365-182X print/ISSN 1477-2574 online # 2006 Taylor & Francis DOI: 10.1080/13651820500472804