A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula

Abstract

INTRODUCTION Cystic artery pseudoaneurysms and cholecystoenteric fistulae represent two rare complications of gallstone disease.PRESENTATION OF CASE An 86 year old male presented to the emergency department with obstructive jaundice, RUQ pain and subsequent upper gastrointestinal bleeding. Upper GI endoscopy revealed bleeding from the medial wall of the second part of the duodenum and a contrast-enhanced computed tomography scan revealed a cystic artery pseudoaneurysm, concurrent cholecystojejunal fistula and gallstone ileus. This patient was successfully managed surgically with open subtotal cholecystectomy, pseudoaneurysm resection and fistula repair.DISCUSSION To date there are very few cases describing haemobilia resulting from a bleeding cystic artery pseudoaneurysm. This report is the first to describe upper gastrointestinal bleeding as a consequence of two synchronous rare pathologies: a ruptured cystic artery pseudoaneurysm causing haemobilia and bleeding through a concurrent cholecystojejunal fistula.CONCLUSION Through this case, we stress the importance of accurate and early diagnosis through ultra- sonography, endoscopy, and contrast-enhanced CT imaging and emphasise that haemobilia should be included in the differential diagnosis of anyone presenting with upper gastrointestinal bleeding. We have demonstrated the success of surgical management alone in the treatment of such a case, but accept that consideration of combined therapeutic approach with angiography be given in the first instance, when available and clinically indicated.

Gallbladder bleeding-related severe gastrointestinal bleeding and shock in a case with end-stage renal disease

“…Until now, 23 cases towing to cystic artery aneurysm with rupture bleeding have been reported. [ 1 ] The cause for cystic artery aneurysm may be GB stone-related GB ulcers eroding into the cystic artery. Other cases of GB bleeding are hemorrhagic perforation because of serious complication of acute cholecystitis with very high mortality (60%) if gangrenous necrosis.…”

Hemobilia Derived from Cystic Artery Pseudoaneurysm

“…In this case, the basal administration of aspirin might be supposed to have been involved in the rupture of the CAP. Besides, a previous study reported that the mechanical stimulation of gallstone was also a risk factor of CAP and hemobilia [2, 6, 7]. Furthermore, a clot can be the origin of biliary obstruction as an acute complications, leading to the formation of gallstone as a late complication of hemobilia [8, 9].…”

A Ruptured Cystic Artery Pseudoaneurysm with Concurrent Cholecystoduodenal Fistula: A Case Report and Literature Review

“…Aneurysmal formation can further progress from patient factors such as atherosclerosis, hypertension, bleeding disorder, and vasculitis. 1 PsA of the cystic artery due to acute cholecystitis is a very rare cause of upper GI bleeding. In a PubMed search of the literature (using key words: pseudoaneurysm, cystic artery, and cholecystitis), only 36 cases have been identified in the English literature.…”

“…A cystic artery pseudoaneurysm is a very rare complication of cholecystitis and is known to cause hemobilia. 1 Cholecystoenteric fistula is also a rare complication of gallstone disease. 1 We report here a very rare case of upper gastrointestinal hemorrhage due to rupture of pseudoaneurysm of the cystic artery with concurrent cholecystoduodenal fistula.…”