The ultrasound appearance of an arterio‐biliary fistula

Abstract

The ultrasound finding of a focal, anechoic lesion in the liver has an extensive differential diagnosis which includes simple cysts, infectious cysts, tumors, abscesses, and hematomas.' -3 We now wish to report a case of an arterio-biliary fistula that presented with a similar appearance. Though the ultrasound appearance of a posttraumatic biliary cyst has been r e p~r t e d ,~ we could find no other case in the English literature in which an arterial communication was present which was responsible for hemobilia. CASE REPORTAn 80-year-old male was admitted with the chief complaint of recurrent gastrointestinal bleeding. Thirty-five years previously, the patient had undergone a cholecystectomy and a vitalium Y tube was placed into his intrahepatic biliary tree for the treatment of a bile duct stricture. The patient did well until 6 months prior to the present admission when he developed recurrent common bile duct stones along with ascending cholangitis. The vitalium tube was removed surgically and the postoperative course was uneventful. One month prior to the present admission he developed persistent melena. A superior mesenteric and inferior mesenteric angiogram failed to reveal a bleeding site. A partial colectomy was performed to remove multiple polyps thought responsible for the bleeding. However, 1 week after surgery the patient developed another episode of melena. A nasogastric aspirate revealed coffee ground material. Therefore, a celiac angiogram was performed which demonstrated an aneurysm originating from the left hepatic artery (Fig. 1). The presumptive diagnosis was that of an arteriobiliary fistula. A real-time ultrasound examination revealed a 3-cm nonpulsatile anechoic lesion in the left lobe of the liver (Fig. 2). Surrounding this lesion were small branching tubular structures that were thought to represent either crowded biliary ducts or branching vessels. These findings were consistent with the preceding diagnosis. Because of spiking temperatures, surgery was performed and a mycotic pseudoaneurysm was resected.

Massive Hemobilia: A Diagnostic and Therapeutic Challenge

“…Thrombus attached to the gallbladder wall may be misinterpreted as a polyp, bile sludge, neoplasm, or gangrenous cholecystitis. Adding Doppler ultrasound can be very useful to detect an aneurysm or a pseudoaneurysm of the hepatic artery [21][22][23]. Abdominal USG was done in all patients, with positive findings in 15 patients (75 %).…”

Intermittent Activity-Induced Hemobilia Caused by Liver Hemangioma

“…We would like to point out that despite the rarity of liver hemangioma induced hemobilia, noninvasive abdominal ultrasound should be integrated in the early diagnostic workup of unclear intestinal bleeding as in all patients with upper gastrointestinal problems. Ultrasonography is a very helpful diagnostic tool in many of the diseases causing hemobilia and may even demonstrate an intrahepatic arteriobiliary fistula [19, 25]. Clots in the gallbladder may be visualized on ultrasonography as heterogeneous echogenic formations without acoustic shadows [26].…”