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.
Few studies have reported the incidence and clinical outcomes of gallstone disease after extended (D2) lymph node dissection for gastric cancer. The present study was designed to retrospectively compare limited (D1) and D2 dissections in terms of gallstone formation, presentation of gallstones, and surgery for gallstone disease. A total of 805 Japanese gastric cancer patients (595 male, 210 female) who underwent curative resection with D1 (n = 490) or D2 (n = 315) dissection were retrospectively reviewed. Of those subjects followed for 70.5 +/- 44.3 months (range: 2-196 months), 102 (12.7%) developed gallstones. The incidence of gallstone formation was higher in the D2 group than in the D1 group (17.8% vs. 9.4%, p = 0.001). The interval between gastrectomy and detection of gallstones was shorter in the D2 group than in the Dl group (18.8 +/- 11.4 months vs. 29.4 +/- 18.3 months, p = 0.002). Of those with gallstones followed for 48.0 +/- 28.6 months (range: 1-158 months), 74 (72.5%) remained asymptomatic, and 15 (14.7%) experienced mild biliary pain. Thirteen patients (12.7%) developed recurrent biliary pain (n = 3) or biliary complications (n = 10; 6 acute cholecystitis, 3 obstructive jaundice, and 1 cholangitis), and required surgical treatment. Surgery was more frequently sought in the D2 group than in the D1 group (19.5% vs. 4.3%, p = 0.033). In conclusion, patients with D2 dissection developed gallstones more frequently and earlier than patients with D1 dissection. Of those with gallstones, patients with D2 dissection required surgery more often than patients with D1 dissection. A closer follow-up should be mandatory for gallstone disease after D2 dissection, but further studies are needed before generalizations can be made.
Pseudoaneurysm of the hepatic artery due to cholecystitis may be very rare, and in our survey of the literature, the present case report is the first case of such a pseudoaneurysm. A 64-year-old woman presented with upper gastrointestinal bleeding and severe epigastric pain. Upper gastrointestinal tract endoscopy revealed blood coming out of the papilla of Vater. Color-Doppler ultrasound imaging showed a pulsatile wave pattern in an echogenic lesion inside the gallbladder. Contrast-enhanced computed tomography demonstrated a 3-cm pseudoaneurysm in the distended gallbladder. Angiography disclosed extravasation originating from the right hepatic artery. Emergency selective transcatheter arterial embolization was performed, with intravascular stainless steel microcoils, and complete occlusion of the pseudoaneurysm was achieved. The patient underwent cholecystectomy with resection of the extrahepatic bile duct and biliary reconstruction in a Roux-en-Y fashion. Macroscopically, the resected gallbladder contained clotted blood and multiple cholesterol stones. Microscopically, the mucosa of the gallbladder showed extensive necrosis and many inflammatory cells. The final diagnosis was pseudoaneurysm of the hepatic artery associated with calculous gangrenous cholecystitis. Although the mechanism of the pseudoaneurysm remains speculative, severe inflammatory reaction in the gallbladder may have infiltrated the liver parenchyma and may have eroded the wall of the hepatic artery, thus forming a pseudoaneurysm. Hemobilia is one of the important differential diagnoses when unexplained gastrointestinal bleeding is observed, especially in patients with hepatobiliary diseases.
We report a rare case of hepatic inflammatory pseudotumor (IPT) after a hepatitis B virus (HBV) infection. Early contrast enhancement on computed tomography (CT) with a washout phenomenon at the delayed phase, and depleted Kupffer cell function on superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) suggested hepatocellular carcinoma (HCC). However, the lack of a tumor capsule, absence of liver cirrhosis, and normal serum levels of alpha-fetoprotein and PIVKA-II (protein induced by vitamin K absence; descarboxyprothrombin) contradicted this diagnosis. We excised the tumor to exclude malignancy, and the histopathological diagnosis was IPT. Recent evidence suggests that this entity has changed from an extremely rare pathology to an established disease. Thus, IPT should be considered in the differential diagnosis of a liver mass with an infectious-inflammatory antecedent. Although surgery is not mandatory, surgical removal is recommended if there is a possibility of malignancy. Further investigations are warranted to elucidate the mechanisms of IPT developing after an HBV infection.
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