Spontaneous intracholecystic hemorrhage due to polyarteritis nodosa

Cystic artery pseudoaneurysm secondary to acute cholecystitis: an unusual cause for haemobilia

Pseudoaneurysm of the cystic artery is a rarely described cause of haemobilia. We report the unusual presentation of upper gastrointestinal haemorrhage due to a pseudoaneurysm of the cystic artery secondary to acute cholecystitis that was complicated by gallbladder perforation and liver abscess in an 88-year-old male. The original CT scan had demonstrated a high density focus in the gallbladder neck that was thought to represent a calculus. Selective embolization of the cystic artery resulted in cessation of the haemorrhage. Owing to the patient’s frailty and comorbidities, he was not considered suitable for cholecystectomy. The case emphasizes the need for a high level of awareness of pseudoaneurysmal disease in association with inflammatory conditions.

Gastrointestinal involvement in polyarteritis nodosa

Polyarteritis nodosa (PAN) is a necrotizing, focal segmental vasculitis that affects predominantly medium-sized arteries in many different organ systems. It is associated with hepatitis B virus (HBV) in about 7% of cases, a decline from about 30% before the mandatory testing of blood products and the widespread vaccination programs. HBV PAN is an early postinfectious process. The hepatitis is silent in most cases, with mild transaminase level increases in 50% of patients. Gastrointestinal involvement occurs in 14% to 65% of patients with PAN. Postprandial abdominal pain from ischemia is the most common symptom. When transmural ischemia develops, there may be necrosis of the bowel wall with perforation, associated with a poor prognosis. Liver involvement occurs in 16% to 56% of patients, although clinical manifestations related to liver disease are quite rare. Acalculous gangrenous cholecystitis may develop owing to arteritis involving the wall of the gallbladder. Microaneurysms on arteriography or computed tomography angiography are characteristic of PAN, but are seen in other conditions. Tissue biopsy may confirm the diagnosis, although involvement is segmental. Corticosteroids are used for non-HBV PAN with cyclophosphamide added for severe disease. For PAN related to HBV, a 2-week course of corticosteroids is begun, with plasma exchanges and an antiviral agent. Corticosteroids and cyclophosphamide have improved patient outcome so that the 1-year survival rate is now about 85%.

Pseudoaneurysm of the cystic artery secondary to cholecystitis as a cause of hemobilia: report of a case

Spontaneous intracholecystic bleeding is very rare. We report herein a very rare case of a pseudoaneurysm of the cystic artery due to acute cholecystitis. A 58-year-old man presented at the emergency department complaining of colicky pain in the right upper quadrant. Dynamic magnetic resonance imaging demonstrated an early-enhanced pooling of contrast material (suggestive of a pseudoaneurysm of the cystic artery) inside the neck of the gallbladder. After the proximal control of the hepatic artery, the patient underwent a cholecystectomy and a ligation of the cystic artery. The resected specimen of the gallbladder showed evidence of a massive intracholecystic hematoma. Proximal to the impacted gallstone in the neck, a 2-cm diameter saccular-type pseudoaneurysm was identified. Although a pseudoaneurysm of the cystic artery is very rare, it should be included in the differential diagnosis of hemobilia. Once the pseudoaneurysm is confirmed, its embolization before a cholecystectomy (which can be attempted laparoscopically) may be useful to ensure the safety of the patient.

Hemobilia from ruptured hepatic artery aneurysm in polyarteritis nodosa

Hemobilia, in patients with the diagnosis of polyarteritis nodosa, is rare at clinical presentation and has a grave prognosis. We describe a case of massive hemobilia, due to aneurysmal rupture, in a patient with polyarteritis nodosa. A 39-year-old man was admitted to the hospital with upper abdominal pain. The patient had a history of partial small bowel resection, for intestinal infarction, about 5 years prior to this presentation. Abdominal computed tomography demonstrated multiple high attenuation areas in the bile duct and gallbladder. Hemobilia with blood seepage was visualized on endoscopic retrograde cholangiopancreatography; this bleeding stopped spontaneously. The following day, the patient developed a massive gastrointestinal bleed with resultant hypovolemic shock. Emergent hepatic angiogram revealed multiple microaneurysms; a communication was identified between a branch of the left hepatic artery and the bile duct. Hepatic arterial embolization was successfully performed. The underlying disease, polyarteritis nodosa, was managed with prednisolone and cyclophosphamide.

Haemobilia

BACKGROUND

This review aims to establish whether increased use of invasive procedures and the trend toward conservative management of major trauma has resulted in an increased incidence of haemobilia.

METHOD

A Medline (http://igm.nlm.nih.gov/)-based search of the English language literature from January 1996 to December 1999 inclusive was performed using the keywords haemobilia, hemobilia, haematobilia and hematobilia. The presentation, aetiology, investigation, management and outcome of 222 cases were reviewed.

RESULTS

Two-thirds of cases were iatrogenic while accidental trauma accounted for 5 per cent. Haemobilia may be major, constituting life-threatening haemorrhage, or minor; it may present many weeks after the initial injury. Diagnosis is most commonly confirmed by angiography. Management is aimed at stopping bleeding and relieving biliary obstruction; 43 per cent of cases were managed conservatively and 36 per cent were managed by transarterial embolization (TAE). Surgery was indicated when laparotomy was performed for other reasons and for failed TAE. The mortality rate was 5 per cent.

CONCLUSIONS

Although the incidence of iatrogenic haemobilia has risen considerably, the bleeding is often minor and can be managed conservatively. When more urgent intervention is required, TAE is usually the treatment of choice. There is no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia.