Rupture of Cystic Artery Pseudoaneurysm: a Rare Complication of Acute Cholecystitis

Hemorrhagic Cholecystitis Due to Rupture of Underlying Anomalous Duplicated Cystic Arteries

Hemorrhagic cholecystitis (HC) is a rare complication that can become rapidly fatal. Patients may present with hematemesis or melena, in addition to other common symptoms of acute cholecystitis. Delay in diagnosing HC postpones early intervention, and patients can quickly decompensate. We present a 33-year-old man with hematemesis and downtrending hemoglobin. Imaging revealed underlying anomalies of duplicate cystic arteries that ruptured, an occurrence never reported in the literature before. Bilateral cystic arteries were embolized successfully. This case demonstrates the importance of early consideration of HC as a differential. Recognition and timely diagnosis prompt urgent intervention, which can reduce morbidity.

An unusual case of acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction: a case report and review of literature

Introduction

Cystic artery pseudoaneurysm rupture presents a rare yet potentially fatal aetiology for upper gastrointestinal (GI) bleed. While uncommon, its incidence has been rising with increased hepatobiliary surgical interventions, predominantly attributed to iatrogenic injury and rarely secondary to acute cholecystitis. Clinical manifestations typically include epigastric pain, upper GI haemorrhage, and obstructive jaundice. Due to its rarity, it is often excluded from initial differential diagnoses.

Case report

This is an unusual case of a 54-year-old male who presented with acute cholecystitis complicated by haemobilia and Mirizzi-like obstruction, in the setting of cystic artery pseudoaneurysm rupture. Initially, urgent transcatheter angiographic embolization of the cystic artery was performed to achieve hemodynamic stability. However, a triphasic computed tomography (CT) scan revealed the first attempt was unsuccessful, necessitating a second embolization. Subsequent imaging confirmed satisfactory embolization; however, a small area of liver necrosis was observed adjacent to the gallbladder. The patient was stable at discharge from the hospital and had an uncomplicated interval cholecystectomy.

Discussion

This case highlights the complexity and challenges associated with diagnosing and managing cystic artery pseudoaneurysm rupture. Diagnosis often relies on arterial phase contrast-enhanced CT scan. While no guideline currently exist, management typically involves achieving hemodynamic stability through Transcatheter angiographic embolization, followed by interval cholecystectomy.

Conclusion

Early recognition and intervention are crucial in managing cystic artery pseudoaneurysm rupture to prevent life-threatening haemorrhagic shock. Clinicians need to consider this rare condition in patients with upper GI bleeding and abnormal liver function tests.

Cystic Artery Pseudoaneurysm: Current Review of Aetiology, Presentation, and Management

Background

Cystic artery pseudoaneurysms are rare. Most commonly, they occur secondary to acute cholecystitis or after a cholecystectomy. Complications include haemobilia, biliary obstruction, and haemorrhage. Given the rarity and associated morbidity, a high index of suspicion is required. This article reviews the current literature on cystic artery pseudoaneurysms to investigate its aetiology, clinical presentation, and management options.

Methods

A broad search of the Medline and PubMed databases was carried through. All peer reviewed literatures published in the English language between 1991 and 2020 with keywords "cystic" and "artery" and "pseudoaneurysm" in the title were selected for review. No further exclusion criteria; all studies yielded from the search were included in the results of this review. Additionally, we present a case of cystic artery pseudoaneurysm treated at our centre and included this in our analysis.

Results

Sixty-seven case reports were found between 1991 and 2020. Aetiologies: Aetiology of cystic artery pseudoaneurysm was found to be cholecystitis in 41 instances (61.2%), cholecystectomy in 18 instances (26.8%), idiopathic in 6 instances (8.9%) cholelithiasis in 1 instance (1.5%), and pancreatitis in 1 instance (1.5%). Complications: Fifty-two cases were complicated by haemobilia (77.6%), 36 by anaemia (53.7%), 25 by biliary obstruction (37.3%), 13 by haemodynamic shock (19.4%), 9 by haemoperitoneum (13.4%), and 6 by contained rupture (8.9%). Most commonly, patients had two or more of these complications. Management: Forty-four patients were managed with endovascular embolisation (65.7%), 21 with endoscopic intervention (31.3%), 18 with open cholecystectomy (26.9%), 13 with laparoscopic cholecystectomy (19.4%), and 6 with pseudoaneurysm ligation (9%). Delayed presentation postcholecystectomy ranged from 8 days to 3 years.

Conclusions

Cystic artery pseudoaneurysms are rare complications of a common operation. The most common clinical presentation is haemobilia, which can be difficult to diagnose clinically. A high index of suspicion and prompt investigation with targeted imaging and intervention is required. This is especially pertinent in gastrointestinal bleeding postlaparoscopic cholecystectomy as a missed diagnosis could cause significant morbidity.

Cystic artery pseudoaneurysm-a rare complication of acute cholecystitis: review of literature

OBJECTIVE

To acquaint with the presentation and management of the cystic artery aneurysm by enriching the reviewed literature with our own experience.

BACKGROUND

Cystic artery pseudoaneurysm is an uncommon entity with varied clinical presentation. Inflammation and trauma are associated with most of the cases. Limited experience with the condition challenges the management of individual cases.

MATERIALS AND METHODS

We retrieved all the reported cases of cystic artery pseudoaneurysm, published up to December 2019, from the PubMed database and excluded those arising as postoperative complications. A total of 59 cases were analyzed, and we also included our experience of managing a case of cystic artery pseudoaneurysm.

RESULTS

Abdominal pain (77.9%) was the most common presentation followed by upper GI bleed (64.4%), while 19 patients (32.2%) had presented with classic Quincke's Triad. Most of the cases were diagnosed following the rupture of the pseudoaneurysm (n = 49, 83.05%). Fifteen patients presented with shock. Hyperbilirubinemia (59.3%) and anemia (55.9%) were the commonest laboratory findings. Although CT angiogram remains the investigation of choice, a conventional angiogram is the gold standard and sufficed as the definitive management in 20 cases. Cholecystectomy formed the definitive management in the rest of the cases. We successfully managed a middle-aged female patient of cystic artery aneurysm with xanthogranulomatous cholecystitis by open cholecystectomy.

CONCLUSION

Cystic artery pseudoaneurysms are amenable to successful management with careful evaluation and timely cholecystectomy or angioembolization or a combination of both.

A Case of Massive Lower Gastrointestinal Bleed from a Cystic Artery Pseudoaneurysm Bleeding through a Cholecystocolic Fistula

Patient: Male, 66-year-old

Final Diagnosis: Cholecystocolic fistula • cystic artery pseudoaneurysm • gastrointestinal bleed

Symptoms: Hematochezia • right upper quadrant

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Cystic artery pseudoaneurysm due to carcinoma of the gallbladder

A 52-year-old man, with known case of hypertension and stroke, presented to us with an upper gastrointestinal bleed and abdominal pain. Ultrasonography of the abdomen showed haematoma within the gallbladder (GB), and Doppler ultrasound was suggestive of an aneurysm arising from the cystic artery (CA). CT of the abdomen showed a well-enhancing thick-walled GB suggestive of malignancy. It also showed the presence of a double CA along with an aneurysm of one of the cystic arteries, haematoma within the GB and haemoperitoneum. Digital subtraction angiography confirmed the presence of double CA and CA pseudoaneurysm. The CA was selective catheterised and embolised with N-butyl cyanoacrylate glue. The patient underwent extended radical cholecystectomy later and was reported to have adenocarcinoma of the GB.

Transarterial Embolization of Iatrogenic Cystic Artery Pseudoaneurysm

Cystic artery pseudoaneurysm (CAP) is a rare entity most often resulting from inflammatory conditions (acute cholecystitis or pancreatitis) or iatrogenic trauma (cholecystectomy). We report the case of a 73-year-old female who presented with abdominal pain and gastrointestinal bleeding after an episode of acute cholecystitis and endoscopic retrograde cholangiopancreatography for choledocolithiasis removal. Computed tomography and angiography revealed a CAP measuring 5 cm. A right hepatic artery transcatheter embolization was performed with glue, excluding the pseudoaneurysm. The next day, the patient underwent open cholecystectomy with ligation of the cystic artery. Later, ischemic hepatitis and abscess developed.