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CASE REPORT – OPEN ACCESSInternational Journal of Surgery Case Reports 5 (2014) 142–144

Contents lists available at ScienceDirect

International Journal of Surgery Case Reports

j ourna l h om epage: www.caserepor ts .com

emobilia as a result of right hepatic artery pseudoaneurysm rupture:n unusual complication of laparoscopic cholecystectomy

hmet Rencuzogullari a,∗, Alexis K. Okohb, Tolga A. Akcama, Emir Charles Roachc,ubilay Dalci a, Abdullah Ulkua

Cukurova University School of Medicine, Department of Surgery, TurkeyAnkara University School of Medicine, Department of Surgery, TurkeyCleveland Clinic, Department of Pathobiology, United States

r t i c l e i n f o

rticle history:eceived 13 November 2013eceived in revised form 3 January 2014ccepted 9 January 2014vailable online 17 January 2014

eywords:aparoscopic cholecystectomyemobiliaseudoaneurysmight hepatic artery

a b s t r a c t

INTRODUCTION: Laparoscopic cholecystectomy has many complications which may be seen due toanatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficientexposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm ofthe right hepatic artery leading to hemobilia after rupturing into the biliary system.PRESENTATION OF CASE: A 43-year-old male patient presented to our clinic 3 weeks post laparoscopiccholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient,Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiogra-phy were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of righthepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed.The patient recovered completely.DISCUSSION: Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic chole-cystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be

precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management ofhemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic orgallbladder bleeding, and for TAE failure.CONCLUSION: In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicionof hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CTangiography should be performed for early diagnosis and management in such patients.

blish-ND lic

© 2014 The Authors. Pu

. Introduction

Laparoscopic cholecystectomy has similar morbidity and mor-ality in experienced hands with open cholecystectomy. However,

any complications may be seen due to anatomical variations, lackf experience of the surgeon or three dimensional visualization,r insufficient exposure of the surgical field. Vascular injuries are

common complication of laparoscopic cholecystectomy. In this

Open access under CC BY-NC

ase report we are presenting a rare entity: pseudoaneurysm of theight hepatic artery leading to hemobilia after rupturing into the

∗ Corresponding author at: Cukurova University School of Medicine, Balcali Hos-ital, Department of General Surgery, Saricam, Adana 01330, Turkey.el.: +90 5321798280; fax: +90 3223386432.

E-mail addresses: rncz1980@gmail.com, arencuz@cu.edu.tr (A. Rencuzogullari).

210-2612 © 2014 The Authors. Published by Elsevier Ltd on behalf of Surgical Associatettp://dx.doi.org/10.1016/j.ijscr.2014.01.005

ed by Elsevier Ltd on behalf of Surgical Associates Ltd.

biliary system. Our diagnostic approach is described and treatmentmethod alongside current treatment modalities is discussed.

2. Case report

A 43-year-old male patient presented to our clinic 3 weekspost laparoscopic cholecystectomy with right upper quadrant pain,melena and hematemesis. The procedure was uneventful with nocomplication during surgery reported in his records. On exami-nation, he was pale; blood pressure was 90/60 mmHg and pulserate was 110 bpm. Mild epigastric tenderness and right upperquadrant pain upon palpation were noted. Laboratory investiga-tions revealed the following: hemoglobin 8.5 g/dl, white cell count8.5 × 109/l, platelet count 335 × 109/l total bilirubin 0.9 mg/dl,direct bilirubin0.3 mg/dl, alanine aminotransferase 477 IU/L (N(normal range for these laboratory results): 13–40 IU/L), aspartateaminotransferase 214 IU/L (N: 10–42 IU/L), and alkaline phos-

ense.

phatase 346 IU/L (125–240 IU/L). Serum amylase levels and otherlaboratory findings were normal.

The patient was hospitalized and resuscitated with colloids and2 units of blood suspension after which he was prepared for an

s Ltd. Open access under CC BY-NC-ND license.

CASE REPORT – OA. Rencuzogullari et al. / International Journal o

Fig. 1. (a) Pre-operative selective right hepatic angiography (arrow points to thep

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of the bleeding site by endoscopic intervention, aneurysm exci-sion, cholecystectomy, and relief of bile duct obstruction. The

seudoaneurysm). (b) Arrow pointing of T-tube in intra-operative cholangiogram.

mergency upper gastrointestinal endoscopy. No bleeding sourceas identified in the stomach and duodenum excluding causes ofemorrhage such as ulcers and malignancy however demonstra-ion of blood flow from the major duodenal papilla raised suspicionsf a hemobilia. To confirm diagnosis Doppler ultrasonography andbdominal computer tomography were performed and the pres-nce of a contrast filled sac bulging from the right hepatic arteryuggestive of hepatic artery pseudoaneurysm was demonstrated onomputed tomography (CT). Selective right hepatic artery angiog-aphy was performed and a pseudoaneurysm was established onhe anterior posterior bifurcation of right hepatic artery (Fig. 1a).

Laparotomy was planned for the treatment as embolization wasot available at the time. The patient was taken into the oper-ting theater, the right hepatic artery was ligated and a T-tubeas placed after choledocotomy (Fig. 1b), then cholangiographyas performed. The biliary system was demonstrated normally on

he cholangiogram and consequently the surgery was completed.he patient tolerated the surgery well and made an uneventfulecovery; his liver function tests gradually returned to normal.ematemesis and melena subsided after surgery.

On postoperative day 21, cholangiography was repeated and the-tube was removed due to the normal demonstration observed.he patient was followed for every three months in the first year

f post-operation and every six months thereafter for three years.ill date, no late complication has occurred.

PEN ACCESSf Surgery Case Reports 5 (2014) 142–144 143

3. Discussion

Hemobilia is defined as hemorrhage into the biliary tract froman aberrant connection or passageway between a blood vessel(splanchnic circulation) and bile duct.1 The first case was reportedby Francis Glisson in 1654, describing the clinical course of ayoung male patient suffering from severe knife injury to theliver.2 In 1871 Quincke described a case of hemobilia stress-ing on the classical clinical triad of biliary colic, jaundice, andgastrointestinal bleeding; however, less than 40% of the casespresent with the complete triad.1,2 The term hemobilia was firstcoined by Sandblom in his 1948 paper entitled “Hemorrhageinto the Biliary Tract Following Trauma: Traumatic Hemobilia”.Hepatic artery aneurysm and liver trauma causing hemobiliamajor-massive and life threatening bleeding3–5 are known to bethe most common causes of this pathologic vascular-biliary con-nection. Occasional cases in the current literature have reportedan association between hemobilia and cholelithiasis, hepaticabscesses,6 acalculous inflammatory conditions (ascariasis,7 chole-cystitis/cholangitis) and neoplasms.

Recent years have seen an increase in iatrogenic causes ofhemobilia with rates varying from 1% with liver biopsy8 or 4%with trans-hepatic cholangiography9 to 14% with transhepaticdrainage,10 40–85% during hepatobiliary surgeries5–7 and lesscommonly laparoscopic cholecystectomy. Pseudoaneurysms ofthe hepatic artery may arise as a complication of laparoscopiccholecystectomy. Clip encroachments, mechanical or thermalinjury during the procedure are likely to be precipitatingfactors.11

Upper GI endoscopy is the diagnostic modality of choice sincebesides ruling out other causes of hemorrhage, can demonstrateblood flow from the major duodenal papilla making recognition CTreveal dilatation of bile ducts with blood within the ducts and gallbladder. Hemobilia may result in CT findings of mixed or uniformhigh attenuation blood within the gallbladder lumen just as gall-stones, vicarious excretion of intravenous contrast, biliary sludge,and milk of calcium bile. The awareness of the attending surgeonshould be drawn to these during the differential diagnostic workup of hemobilia on CT.12–15

In previous years, patients with hemobilia needed conven-tional angiography to look for a suspected vascular abnormality,such as pseudoaneurysm however with the advents of the multi-detector CT (MDCT) and advancements in 3D imaging software inthe form of volume rendering; today CT is the preferred choiceas a primary vascular imaging technique for hemobilia eval-uation. CT angiography using MDCT is fast replacing catheterarteriography for diagnosis of pseudoaneurysms and the latteris now used for therapeutic procedure guidance only.15 Despiterecent advances in imaging modalities and techniques, selectiveright hepatic angiography remains vital in the diagnosis of uppergastrointestinal hemorrhage following laparoscopic cholecystec-tomy.

Embolization offers the advantage of minimally invasive treat-ment in hemodynamically unstable patients, permits distal aswell as proximal control of the hepatic artery, and is an effec-tive treatment for this potentially life-threatening complication.16

Today, transarterial embolization (TAE) is the gold standard forthe management of hemobilia, and if it fails, the next step inmanagement is surgical. Surgery is limited to extra-hepatic orgallbladder bleeding, and for TAE failure. Depending on the eti-ology of hemobilia, surgery involves direct exploration of theliver with possible hepatic resection, ligation and/or ballooning

period between establishment of diagnosis and surgical inter-vention in the absence of embolization as a treatment choice is

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CASE REPORT44 A. Rencuzogullari et al. / International Jou

ritical and should be managed carefully by the attending sur-eon.

In conclusion, patients undergoing laparoscopic cholecystec-omy should be observed with respect to complications in theost-operative course. In cases of GI bleeding the awareness of theurgeon should be drawn to a clinical suspicion of hemobilia and annderlying hepatic artery pseudoaneurysm that can arise as a com-lication. CT angiography should be performed for early diagnosisnd management in such patients.

onflict of interest

None.

unding

None.

thical approval

Written informed consent was obtained from the patient forublication of this case report and accompanying images. A copyf the written consent is available for review by the Editor-in-Chieff this journal on request

uthor contributions

Patient management and surgery were done by Ahmet Ren-

uzogullari, Tolga Akcam, Kubilay Dalci and Abdullah Ulku. Theiterature was reviewed by Emir Charles Roach. Emir Charles Roachnd Kubilay Dalci were involved in the decision making process.he manuscript was drafted and edited by all authors.

1

1

pen Accesshis article is published Open Access at sciencedirect.com. It is distribermits unrestricted non commercial use, distribution, and reproductredited.

PEN ACCESSf Surgery Case Reports 5 (2014) 142–144

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