PICTURES IN DIGESTIVE PATHOLOGY
1130-0108/2015/107/6/375-376 Revista españolade enfeRmedades digestivas
CopyRight © 2015 aRán ediCiones, s. l. Rev esp enfeRm dig (Madrid
Vol. 107, N.º 6, pp. 375-376, 2015
Pseudoaneurysm of the cystic artery: An uncommon cause of upper gastrointestinal bleeding in a case of xanthogranulomatous cholecystitis
Carmen Muñoz-Villafranca1, Íñigo García-Kamirruaga1, Pilar Gómez-García2, Víctor Atín-del-Campo2, Victoria Bárcena-Robredo3, Alexander Aguinaga-Alesanco4 and Ángel Calderón-García1
Departments of 1Gastroenterology, 2Surgery and 3Diagnostic Radiology. Hospital Universitario de Basurto. Bilbao, Vizcaya. Spain. 4Department of Diagnostic Radiology. Hospital Universitario de Cruces. Baracaldo, Vizcaya. Spain
Pseudoaneurysm of the cystic artery is a very rare entity; only a few cases have been reported in the literature (1).
We present the case of a 74-year-old male admitted for pain in the right lower quadrant of the abdomen. The emergency abdom- inal CT scan showed abnormal structural findings in the gallblad- der, with hypodense area, cholelithiasis, and involvement of the fat around the gallbladder. The findings suggesting xanthogran- ulomatous cholecystitis were confirmed by needle aspiration cytology. His course was unsatisfactory and, on day 14, he had an episode of pain in the upper gastrointestinal tract and melaena.
The suspicion of haemobilia was confirmed by endoscopy. In the lower part of the ampulla of the duodenum, we identified a leaky hole into a cylindrical cavity and observed branching compatible with the biliary tree (Fig. 2).
Magnetic resonance imaging showed a 1.8 cm lesion compat- ible with a pseudoaneurysm of the cystic artery (Fig. 3). Given the severity of the bleeding, selective embolisation of the cystic artery was performed on an emergency basis, by selective cathe- terisation of the hepatic artery and supraselective catheterisation
Fig. 1. Contrast-enhanced multidetector computed tomography image.
Gallbladder not clearly defined, bed filled with a hypodense areas and fat involvement. Nodular accumulation of contrast medium inside the gallbladder, compatible with a pseudoaneurysm of the cystic artery.
Fig. 2. Gastroscopy. A hole leaking blood was observed, in the lower part of the ampulla of the duodenum, close to the superior duodenal flexure.
Passing through the hole, we observed a cylindrical cavity with necrotic walls and branching resembling the biliary tree.
Fig. 3. Axial T2-weighted half-Fourier acquisition single-shot turbo spin- echo MRI. Accumulation of the contrast media in the ampulla of the duodenum associated with an enterobiliary fistula. Diffuse thickening of the gallbladder, suggestive of xanthogranulomatous cholecystitis.
A 1.8 cm diameter, rounded lesion in the lumen of the gallbladder, compatible with a pseudoaneurysm of the cystic artery (arrow).
376 C. MUÑOZ-VILLAFRANCA ET AL. Rev esp enfeRm Dig (maDRiD)
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of the cystic artery. We used 500 to 700 µm Contour Micro- spheres and three coils (Fig. 4), and succeeded in stopping the haemorrhage immediately.
Despite the high incidence of biliary diseases in our setting, there are very few cases of digestive haemorrhage due to hae- mobilia (2). Although the origin of the pseudoaneurysm is not clear, it seems that erosion of the artery wall, due to inflam- matory processes associated with cholecystitis, could have led its formation (3). As for the treatment of choice, most authors recommend arteriography with selective embolisation by inter- ventional radiology (4).
REFERENCES
1. Komatsu Y, OritoH, Sakurada M, et al. Report of a case: Pseudoaneu- rysm of the cystic artery with hemobilia treated by arterial emboliza- tion. Journal of Medical Cases 2011;2:178-83.
2. Sousa HT, Amaro P, Brito J, et al. Hemobilia due to pseudoaneu- rysm of the cystic artery. Gastroentérologie Clinique et Biologique 2009;33:80-2.
3. Anand U, Kumar ThaKur S, Kumar S, et al. Idiopathic cystic artery aneurysm complicaded with hemobilia. Annals Of Gastroenterology 2011;24:134-6.
4. Ahmed I, Tanveer UH, Sajjad Z, et al. Cystic artery pseudoaneurysm:
A complication of xantogranulomatous cholecystitis. B J Radiology 2010;83:165-7.
Fig. 4. Angiography. Microcatheter in the cystic artery. The pseudoaneurysm filled with contrast medium, indicating active bleeding. Increased vascularization in the gallbladder. After placing the coil, the pseudoaneurysm no longer filled with contrast medium.
