Life-threatening hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy: report of a case

Abstract

BackgroundHemobilia is a rare but lethal biliary tract complication. There are several causes of hemobilia which might be classified as traumatic or nontraumatic. Hemobilia caused by pseudoaneurysm might result from hepatobiliary surgery or percutaneous interventional hepatobiliary procedures. However, to our knowledge, there are no previous reports pertaining to hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy.Case presentationA 65-year-old male was admitted to our hospital because of acute calculous cholecystitis and cholangitis. He underwent cholecystectomy, choledocholithotomy via a right upper quadrant laparotomy and a temporary T-tube choledochostomy was created. However, on the 19th day after operation, he suffered from sudden onset of hematemesis and massive fresh blood drainage from the T-tube choledochostomy. Imaging studies confirmed the diagnosis of pseudoaneurysm associated hemobilia. The probable association of T-tube choledochostomy with pseudoaneurysm and hemobilia is also demonstrated. He underwent emergent selective microcoils emobolization to occlude the feeding artery of the pseudoaneurysm.ConclusionsPseudoaneurysm associated hemobilia may occur after T-tube choledochostomy. This case also highlights the importance that hemobilia should be highly suspected in a patient presenting with jaundice, right upper quadrant abdominal pain and upper gastrointestinal bleeding after liver or biliary surgery.

Hemobilia due to arteriobiliary fistula complicating ERCP for residual bile duct stone in a case of Mirizzi syndrome

“…The priority is to localize and stop the bleeding. Selective angiography is the gold standard to identify and stop the bleeding by embolizing the offending vessel 12345. Angiography, however, failed to demonstrate the contrast leak in our patient, possibly because of the intermittent nature of the bleeding and the absence of a pseudoaneurysm.…”

“…In addition, blunt or penetrating liver trauma can cause hemobilia 1. Other causes include bile duct stones, biliary varices, benign and malignant tumors of the bile duct, liver surgery and transplantation, congenital or acquired vascular aneurysms and hepatitis 1245…”

“…This must have led to the inflammatory adhesions which developed between the common hepatic duct and the right hepatic artery. The anatomical position of the bile duct and the right hepatic artery in the hepatoduodenal ligament facilitates formation of these adhesions 5. The ERCP guidewire, the attempt at stone extraction and stent placement may have led to an accidental puncture of the bile duct resulting in the formation of an arteriobiliary fistula.…”

Coil migration into the common bile duct after embolization of a hepatic artery pseudoaneurysm

“…The common symptoms are upper gastrointestinal hemorrhage, upper abdominal pain, and jaundice. To our knowledge, there has been only one prior report of hemobilia caused by hepatic artery pseudoaneurysm after T-tube choledochostomy [2]. Mechanical compression of the bile duct mucosa and the adjacent part of the hepatic artery by the T-tube may lead to blood vessel erosion and formation of a pseudoaneurysm.…”

Hemobilia secundaria a pseudoaneurisma hepático tras coledocostomía mediante tubo de Kehr

“…Son pocos los trabajos publicados que describan la asociación de un pseudoaneurisma con hemobilia tras una coledocostomía mediante tubo de Kehr. Se trata de una causa poco frecuente, que debe considerarse en la hemobilia iatrogénica 3 . Nuestro diagnóstico está fundamentado principalmente en la proximidad del pseudoaneurisma al tubo de coledocostomía.…”