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Hemobilia due to cystic artery pseudoaneurysm
The American Journal of Surgery 191 (2006) 797–798
Clinical image
Hemobilia due to cystic artery pseudoaneurysm Lena Sibulesky, M.D., Mark Ridlen, M.D., Victor E. Pricolo, M.D.* Department of Surgery, Brown University School of Medicine, Rhode Island Hospital, 2 Dudley St., Suite 470, Providence, RI 02905, USA Manuscript received March 4, 2005; revised manuscript July 5, 2005
Upper gastrointestinal bleeding from a biliary tree source is an uncommon event. This phenomenon was first named “hemobilia” by Sandblom in 1948, when he described bleeding into the biliary system after a subcapsular liver injury [1]. The most common cause of this disorder is iatrogenic or accidental traumatic injury to the liver, which accounts for more than 50% of cases. Iatrogenic injury can be a consequence of percutaneous liver procedures and hepatobiliary operations. Other possible causes are gallstones, cholecystitis, hepatic or bile duct tumors, vascular abnormalities such as aneurysms, bleeding disorders, and certain infections (typically parasitic). Spontaneous intracholecystic bleeding is very rare. It has been described in patients with hemophilia [2], von Willebrand’s disease [3], metachromatic leukodystrophy [4], and polyarteritis nodosa [5]. We report a patient with hemobilia secondary to bleeding into gallbladder due to disruption of an aneurismal vessel supplying the gallbladder wall. Only few cases have been reported in the literature previously. A 72 year-old man presented to the emergency department complaining of intermittent upper abdominal pain occasionally associated with melanotic stools for 3 weeks. On the day of admission, the patient had experienced a severe right upper quadrant pain, followed by an episode of hematemesis. He denied any fevers, chills, or sweats. He denied any history of trauma or recent surgery. His past medical history was unremarkable. He was afebrile, and his blood pressure and pulse were normal. Physical examination revealed a well-nourished man in no distress with a soft, nontender abdomen. His laboratory studies showed white blood cell count 11.1, hemoglobin 9.4, partial thromboplastin time 20.8, INR 1.0, AST 164, ALT 163, alkaline phosphatase 272, T bili 1.8, D bili 1.1. An upper endoscopy revealed gastritis and blood at the papilla of Vater. A gall-
* Corresponding author. Tel.: ⫹1-401-553-8306; fax: ⫹1-401-8682315. E-mail address: [email protected]
bladder sonogram showed a gallbladder filled with debris, consistent with blood clot by color Doppler flow studies. Gallstones were not visualized. Intrahepatic and extrahepatic ducts were not dilated. A triple-phase computed tomography of the abdomen demonstrated a focus of dense contrast enhancement in the anterior aspect of the gallbladder wall, consistent with active extravasation of blood (Fig. 1). At laparoscopy, the extrahepatic biliary system was very dilated. Once the cystic duct was incised to perform an intraoperative cholangiogram, a large amount of partially clotted blood started draining from the biliry system, mandating conversion to an open procedure. After proper evacuation of blood clots, the intraoperative cholangiogram showed no biliary defects. After cholecystectomy, gross examination of the resected gallbladder revealed intracholecystic blood clots and a mass attached to the wall of the gallbladder (Fig. 2). Pathologic examination of this mass revealed an organized blood clot, while the gallbladder wall had an unusually distended aneurysmal artery with thickened wall. The patient did well postoperatively and was discharged home without further evidence of bleeding. Hemobilia is a rare condition, but should be included in the differential diagnosis of gastrointestinal bleeding. It classically presents as right upper quadrant pain, jaundice and gastrointestinal bleeding, either as hematemesis or melena. However, most patients do not demonstrate the triad and each symptom has about two-thirds incidence. Acute bleeding usually first causes pain, followed by hematemesis or melena. Tests used for diagnosis depend on history and presentation. Upper endoscopy is employed in patients who present with upper gastrointestinal bleeding. Endoscopy with a side-viewing duodenoscope may be optimal. Hemobilia is likely to be the cause of bleeding if fresh blood or clot are seen oozing from the papilla of Vater. ERCP can be used in cases were patients present with a clinical picture suggestive of bile duct obstruction. Ultrasound and computed tomography are helpful in identification of tumor,
0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2005.07.041
798
L. Sibulesky et al. / The American Journal of Surgery 191 (2006) 797–798
Fig. 1. A triple-phase computed tomography scan of the abdomen showing a focus of dense contrast enhancement in the anterior aspect of the gallbladder wall.
stone disease, and parenchymal and associated vascular injuries. Fresh blood clots within gallbladder are highly echogenic and appear as non-shadowing, nonmobile masses. Also, changes suggestive of acute cholecystits can be seen. Computed tomography may identify evidence of bleeding by pooling of contrast material, intraluminal clots, and biliary dilatation. In many cases such as trauma or known tumor, hepatic angiograpy should be considered early as a diagnostic and therapeutic modality. In our patient, the triple-phase computed tomography was diagnostic in showing that the bleeding originated from the gallbladder. In such cases, cholecystectomy is curative.
Fig. 2. Resected gallbladder with a mass attached to the inner wall.
References [1] Sandblom P. Hemorrhage into the biliary tract following trauma: “traumatic hemobilia.” Surgery 1948;24:571– 86. [2] Laing FC, Frates MC, Feldstein VA, et al. Hemobilia. Sonographic appearances in the gallbladder and biliary tree with emphasis on intracholecysic blood. J Ultrasound Med 1997;16:537– 43. [3] Kaafarani H, Taher A, Hadded MC, et al. Spontaneous intracholecystic bleeding in a patient with von Willebrand’s disease. Gastrointest Endosc 2003;58:809 –11. [4] Vettoretto N, Giovanetti M, Regina P, et al. Hemorrhagic cholecystitis as likely cause of nontraumatic hemobilia in metachromatic leukodystrophy: report of a case. Ann Ital Chir 2001;72:725– 8. [5] Mori M, Kohzaki S, Makino K, et al. Spontaneous intracholecystic hemorrhage due to polyarteritis nodosa. J Comput Assist Tomogr 1998;22:730 –1.
Clinical image
Hemobilia due to cystic artery pseudoaneurysm Lena Sibulesky, M.D., Mark Ridlen, M.D., Victor E. Pricolo, M.D.* Department of Surgery, Brown University School of Medicine, Rhode Island Hospital, 2 Dudley St., Suite 470, Providence, RI 02905, USA Manuscript received March 4, 2005; revised manuscript July 5, 2005
Upper gastrointestinal bleeding from a biliary tree source is an uncommon event. This phenomenon was first named “hemobilia” by Sandblom in 1948, when he described bleeding into the biliary system after a subcapsular liver injury [1]. The most common cause of this disorder is iatrogenic or accidental traumatic injury to the liver, which accounts for more than 50% of cases. Iatrogenic injury can be a consequence of percutaneous liver procedures and hepatobiliary operations. Other possible causes are gallstones, cholecystitis, hepatic or bile duct tumors, vascular abnormalities such as aneurysms, bleeding disorders, and certain infections (typically parasitic). Spontaneous intracholecystic bleeding is very rare. It has been described in patients with hemophilia [2], von Willebrand’s disease [3], metachromatic leukodystrophy [4], and polyarteritis nodosa [5]. We report a patient with hemobilia secondary to bleeding into gallbladder due to disruption of an aneurismal vessel supplying the gallbladder wall. Only few cases have been reported in the literature previously. A 72 year-old man presented to the emergency department complaining of intermittent upper abdominal pain occasionally associated with melanotic stools for 3 weeks. On the day of admission, the patient had experienced a severe right upper quadrant pain, followed by an episode of hematemesis. He denied any fevers, chills, or sweats. He denied any history of trauma or recent surgery. His past medical history was unremarkable. He was afebrile, and his blood pressure and pulse were normal. Physical examination revealed a well-nourished man in no distress with a soft, nontender abdomen. His laboratory studies showed white blood cell count 11.1, hemoglobin 9.4, partial thromboplastin time 20.8, INR 1.0, AST 164, ALT 163, alkaline phosphatase 272, T bili 1.8, D bili 1.1. An upper endoscopy revealed gastritis and blood at the papilla of Vater. A gall-
* Corresponding author. Tel.: ⫹1-401-553-8306; fax: ⫹1-401-8682315. E-mail address: [email protected]
bladder sonogram showed a gallbladder filled with debris, consistent with blood clot by color Doppler flow studies. Gallstones were not visualized. Intrahepatic and extrahepatic ducts were not dilated. A triple-phase computed tomography of the abdomen demonstrated a focus of dense contrast enhancement in the anterior aspect of the gallbladder wall, consistent with active extravasation of blood (Fig. 1). At laparoscopy, the extrahepatic biliary system was very dilated. Once the cystic duct was incised to perform an intraoperative cholangiogram, a large amount of partially clotted blood started draining from the biliry system, mandating conversion to an open procedure. After proper evacuation of blood clots, the intraoperative cholangiogram showed no biliary defects. After cholecystectomy, gross examination of the resected gallbladder revealed intracholecystic blood clots and a mass attached to the wall of the gallbladder (Fig. 2). Pathologic examination of this mass revealed an organized blood clot, while the gallbladder wall had an unusually distended aneurysmal artery with thickened wall. The patient did well postoperatively and was discharged home without further evidence of bleeding. Hemobilia is a rare condition, but should be included in the differential diagnosis of gastrointestinal bleeding. It classically presents as right upper quadrant pain, jaundice and gastrointestinal bleeding, either as hematemesis or melena. However, most patients do not demonstrate the triad and each symptom has about two-thirds incidence. Acute bleeding usually first causes pain, followed by hematemesis or melena. Tests used for diagnosis depend on history and presentation. Upper endoscopy is employed in patients who present with upper gastrointestinal bleeding. Endoscopy with a side-viewing duodenoscope may be optimal. Hemobilia is likely to be the cause of bleeding if fresh blood or clot are seen oozing from the papilla of Vater. ERCP can be used in cases were patients present with a clinical picture suggestive of bile duct obstruction. Ultrasound and computed tomography are helpful in identification of tumor,
0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2005.07.041
798
L. Sibulesky et al. / The American Journal of Surgery 191 (2006) 797–798
Fig. 1. A triple-phase computed tomography scan of the abdomen showing a focus of dense contrast enhancement in the anterior aspect of the gallbladder wall.
stone disease, and parenchymal and associated vascular injuries. Fresh blood clots within gallbladder are highly echogenic and appear as non-shadowing, nonmobile masses. Also, changes suggestive of acute cholecystits can be seen. Computed tomography may identify evidence of bleeding by pooling of contrast material, intraluminal clots, and biliary dilatation. In many cases such as trauma or known tumor, hepatic angiograpy should be considered early as a diagnostic and therapeutic modality. In our patient, the triple-phase computed tomography was diagnostic in showing that the bleeding originated from the gallbladder. In such cases, cholecystectomy is curative.
Fig. 2. Resected gallbladder with a mass attached to the inner wall.
References [1] Sandblom P. Hemorrhage into the biliary tract following trauma: “traumatic hemobilia.” Surgery 1948;24:571– 86. [2] Laing FC, Frates MC, Feldstein VA, et al. Hemobilia. Sonographic appearances in the gallbladder and biliary tree with emphasis on intracholecysic blood. J Ultrasound Med 1997;16:537– 43. [3] Kaafarani H, Taher A, Hadded MC, et al. Spontaneous intracholecystic bleeding in a patient with von Willebrand’s disease. Gastrointest Endosc 2003;58:809 –11. [4] Vettoretto N, Giovanetti M, Regina P, et al. Hemorrhagic cholecystitis as likely cause of nontraumatic hemobilia in metachromatic leukodystrophy: report of a case. Ann Ital Chir 2001;72:725– 8. [5] Mori M, Kohzaki S, Makino K, et al. Spontaneous intracholecystic hemorrhage due to polyarteritis nodosa. J Comput Assist Tomogr 1998;22:730 –1.