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Acute cholecystitis with massive upper gastrointestinal bleed: a case report and review of the literature.

Saluja SS, Ray S, Gulati MS, Pal S, Sahni P, Chattopadhyay TK - BMC Gastroenterol (2007)

Bottom Line: Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer.She presented with haematemesis and melaena associated with postural symptoms.Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Gastrointestinal surgery, AIIMS, Ansari Nagar, New Delhi, India. sundeepsaluja@yahoo.co.in

ABSTRACT

Background: Cystic artery pseudoaneurysm is a rare complication following cholecystitis. Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer. Thirteen patients with cystic artery pseudoaneurysm have been reported in the literature but only 2 of them presented with UGIH alone.

Case presentation: We report a 43-year-old woman who developed a cystic artery pseudoaneurysm following an episode of acute cholecystitis. She presented with haematemesis and melaena associated with postural symptoms. Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum. Ultrasonography detected gallstones and a pseudoaneurysm at the porta hepatis. Selective hepatic angiography showed two small pseudoaneurysms in relation to the cystic artery, which were selectively embolized. However, the patient developed abdominal signs suggestive of gangrene of the gall bladder and underwent an emergency laparotomy. Cholecystectomy with common bile duct exploration along with repair of the duodenal rent, and pyloric exclusion and gastrojejunostomy was done.

Conclusion: This case illustrates the occurrence of a rare complication (pseudoaneurysm) following cholecystitis with an unusual presentation (UGIH). Cholecystectomy, ligation of the pseudoaneurysm and repair of the intestinal communication is an effective modality of treatment.

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A: Flush aortogram showing pseudoaneurysms in the coeliac artery territory. B: Selective hepatic artery angiogram showing two small pseudoaneurysms (arrow) in relation to the cystic artery.
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Figure 1: A: Flush aortogram showing pseudoaneurysms in the coeliac artery territory. B: Selective hepatic artery angiogram showing two small pseudoaneurysms (arrow) in relation to the cystic artery.

Mentions: An ultrasound revealed a thick walled gall bladder with multiple calculi and a normal common bile duct (CBD) and portal vein. It also detected a rounded heteroechoic lesion anterior to the portal vein with a central anechoic component, which showed flow on Doppler suggestive of an aneurysm. A contrast enhanced computed tomography scan (CECT scan) was done, which revealed similar findings suggestive of a pseudoaneurysm. A digital subtraction angiography (DSA) was then done to localize the site of the aneurysm. The selective hepatic artery angiogram showed two small pseudoaneurysms in relation to the cystic artery (Figure 1) and a normal superior mesenteric artery. As the patient had bled recently and had had an episode of acute cholecystitis (two weeks ago), embolization of the pseudoaneurysm was planned. After super selective catheterization of the cystic artery, the aneurysm was embolized using gel foam and micro coils (Figure 2). Subsequently, the patient was monitored in the intensive care unit where she remained stable haemodynamically and did not have any further episode of UGIH. A day later the patient had increasing abdominal pain and appearance of peritoneal signs localized to the RUQ of the abdomen. These clinical features suggested the possibility of gangrene of the gallbladder following embolization of the cystic artery. At laparotomy, there were dense adhesions in the gallbladder fossa. The gallbladder was inflamed, thickened, and contained multiple gallstones and blood clots. The cystic duct was obliterated with a stone that was impacted in the Hartmann's pouch. The proximal CBD was dilated (1.5 cm). There was a 3 × 3 cm pseudoaneurysm, which had ruptured into the first part of the duodenum. The small bowel and colon were filled with blood clots. A partial cholecystectomy was done as the Calot's triangle was obliterated with dense adhesions. The cut section of the gall bladder showed a grossly inflamed and oedematous wall but no evidence of gangrene. As the proximal CBD was dilated and the bilirubin had increased to 3.8 mg/dl just prior to surgery, it was explored. There were blood clots in the CBD which were removed and a T-tube was placed. The pseudoaneurysm was evacuated and the duodenal rent was closed over a 16F T-tube placed through a small duodenotomy in the lateral wall of the second part of the duodenum. A pyloric exclusion with gastrojejunostomy and feeding jejunostomy were done as the duodenal repair had been done on a severely inflammed and oedematous duodenum. Postoperatively, she was kept nil by mouth and given parenteral crystalloids, antibiotics and proton pump inhibitors. She had a leak from the duodenal closure on postoperative day 4 which was managed conservatively with maintenance of fluid and electrolyte balance, adequate drainage of the duodenal effluents, appropriate parenteral antibiotics and enteral nutrition using jejunostomy feeds. Three weeks later a gastrograffin study showed no leak from the duodenum. She was then started on oral feeds and discharged after a total hospital stay of 4 weeks. Eighteen months later on follow-up she was doing well except for an incisional hernia at the lateral edge of her operative wound.


Acute cholecystitis with massive upper gastrointestinal bleed: a case report and review of the literature.

Saluja SS, Ray S, Gulati MS, Pal S, Sahni P, Chattopadhyay TK - BMC Gastroenterol (2007)

A: Flush aortogram showing pseudoaneurysms in the coeliac artery territory. B: Selective hepatic artery angiogram showing two small pseudoaneurysms (arrow) in relation to the cystic artery.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC1851966&req=5

Figure 1: A: Flush aortogram showing pseudoaneurysms in the coeliac artery territory. B: Selective hepatic artery angiogram showing two small pseudoaneurysms (arrow) in relation to the cystic artery.
Mentions: An ultrasound revealed a thick walled gall bladder with multiple calculi and a normal common bile duct (CBD) and portal vein. It also detected a rounded heteroechoic lesion anterior to the portal vein with a central anechoic component, which showed flow on Doppler suggestive of an aneurysm. A contrast enhanced computed tomography scan (CECT scan) was done, which revealed similar findings suggestive of a pseudoaneurysm. A digital subtraction angiography (DSA) was then done to localize the site of the aneurysm. The selective hepatic artery angiogram showed two small pseudoaneurysms in relation to the cystic artery (Figure 1) and a normal superior mesenteric artery. As the patient had bled recently and had had an episode of acute cholecystitis (two weeks ago), embolization of the pseudoaneurysm was planned. After super selective catheterization of the cystic artery, the aneurysm was embolized using gel foam and micro coils (Figure 2). Subsequently, the patient was monitored in the intensive care unit where she remained stable haemodynamically and did not have any further episode of UGIH. A day later the patient had increasing abdominal pain and appearance of peritoneal signs localized to the RUQ of the abdomen. These clinical features suggested the possibility of gangrene of the gallbladder following embolization of the cystic artery. At laparotomy, there were dense adhesions in the gallbladder fossa. The gallbladder was inflamed, thickened, and contained multiple gallstones and blood clots. The cystic duct was obliterated with a stone that was impacted in the Hartmann's pouch. The proximal CBD was dilated (1.5 cm). There was a 3 × 3 cm pseudoaneurysm, which had ruptured into the first part of the duodenum. The small bowel and colon were filled with blood clots. A partial cholecystectomy was done as the Calot's triangle was obliterated with dense adhesions. The cut section of the gall bladder showed a grossly inflamed and oedematous wall but no evidence of gangrene. As the proximal CBD was dilated and the bilirubin had increased to 3.8 mg/dl just prior to surgery, it was explored. There were blood clots in the CBD which were removed and a T-tube was placed. The pseudoaneurysm was evacuated and the duodenal rent was closed over a 16F T-tube placed through a small duodenotomy in the lateral wall of the second part of the duodenum. A pyloric exclusion with gastrojejunostomy and feeding jejunostomy were done as the duodenal repair had been done on a severely inflammed and oedematous duodenum. Postoperatively, she was kept nil by mouth and given parenteral crystalloids, antibiotics and proton pump inhibitors. She had a leak from the duodenal closure on postoperative day 4 which was managed conservatively with maintenance of fluid and electrolyte balance, adequate drainage of the duodenal effluents, appropriate parenteral antibiotics and enteral nutrition using jejunostomy feeds. Three weeks later a gastrograffin study showed no leak from the duodenum. She was then started on oral feeds and discharged after a total hospital stay of 4 weeks. Eighteen months later on follow-up she was doing well except for an incisional hernia at the lateral edge of her operative wound.

Bottom Line: Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer.She presented with haematemesis and melaena associated with postural symptoms.Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Gastrointestinal surgery, AIIMS, Ansari Nagar, New Delhi, India. sundeepsaluja@yahoo.co.in

ABSTRACT

Background: Cystic artery pseudoaneurysm is a rare complication following cholecystitis. Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer. Thirteen patients with cystic artery pseudoaneurysm have been reported in the literature but only 2 of them presented with UGIH alone.

Case presentation: We report a 43-year-old woman who developed a cystic artery pseudoaneurysm following an episode of acute cholecystitis. She presented with haematemesis and melaena associated with postural symptoms. Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum. Ultrasonography detected gallstones and a pseudoaneurysm at the porta hepatis. Selective hepatic angiography showed two small pseudoaneurysms in relation to the cystic artery, which were selectively embolized. However, the patient developed abdominal signs suggestive of gangrene of the gall bladder and underwent an emergency laparotomy. Cholecystectomy with common bile duct exploration along with repair of the duodenal rent, and pyloric exclusion and gastrojejunostomy was done.

Conclusion: This case illustrates the occurrence of a rare complication (pseudoaneurysm) following cholecystitis with an unusual presentation (UGIH). Cholecystectomy, ligation of the pseudoaneurysm and repair of the intestinal communication is an effective modality of treatment.

Show MeSH
Related in: MedlinePlus