Teaching Case

A 33-year-old woman who underwent laparoscopic cholecystectomy presented with abdominal pain, vomiting, jaundice and melena. Hemoglobin was 7g/dl; total serum bilirubin was 12 mg/dl with deranged liver function tests. Radiological workup was done using ultrasound, magnetic resonance cholangiopancreatography (MRCP) and contrast-enhanced CT.

On ultrasound examination, an ill-defined collection was found in the gastrohepatic area, and dilated common hepatic duct (CHD) and intrahepatic biliary duct dilatation (IHBRD) were noted. Later MRCP revealed dilated CHD filled with clotted blood products (Figure 1). At the porta hepatis region, a well-defined heterogenous T2 hypointensity was noted (Figure 2), likely a vascular aneurysm that was causing extrinsic compression over the CHD. Contrast-enhanced CT was done later, after two consecutive ERCP procedures, that showed hepatomegaly with multiple non-enhancing, well-defined hypodense lesions in both the lobes of the liver that are likely cholangitic abscesses (Figure 3). Contrast-filled outpouching arising from the branch of the right hepatic artery measuring 15x14 mm was noted, which was likely a pseudoaneurysm. A small fistulous tract was seen arising from the pseudoaneurysm opening into the common bile duct (CBD). CBD is normal in calibre, filled with IV contrast in the arterial phase (Figures 4 and 5). Bowel loops appear oedematous and ischemic (Figure 6) due to hypoperfusion status. The wall of the duodenum appears to be lined with IV contrast material (Figure 7).

Laparoscopic cholecystectomy can cause complications like biliary and vascular injuries in a few instances. Vascular injuries usually involve the right hepatic artery or cystic artery branches, while portal vascular injuries are less frequent. One uncommon yet severe complication is the development of hepatic artery pseudoaneurysm, with a reported incidence of 0.6% [1]. The occurrence of haemobilia following iatrogenic pseudoaneurysms is very rare, having an incidence of 0.001% [1]. The primary mechanism behind pseudoaneurysm development is mostly iatrogenic, arising from factors like blood vessel transection due to mechanical or thermal injuries, insertion of clips, leakage of bile acids, intraoperative adhesions, and occasional associations with anatomical variants [2]. Patients typically present with complaints of abdominal pain and discomfort. Quincke’s triad (jaundice, right upper quadrant pain, and upper gastrointestinal bleeding) is a classic presentation. Cases presenting with jaundice, GI bleeding leading to haemobilia, melena, and hemoperitoneum are rare. Diagnosis can be confirmed through history, upper GI endoscopy, Doppler, contrast-enhanced CT, and catheter angiography; however, selective celiac and SMA angiography are considered the most reliable diagnostic tests [3].

In this present case scenario, the patient underwent laparoscopic cholecystectomy for cholelithiasis. After surgery, the patient experienced persistent post-operative biliary leak, prompting an ERCP procedure. The right hepatic duct was cannulated, and biliary stenting was performed with plastic biliary stent placement. Subsequently, she developed severe abdominal pain and uncontrolled jaundice. During a repeated ERCP, it was discovered that the CBD stent was incorrectly placed in a false tract and was immediately removed. Follow-up MRCP was done the next day, which revealed bilobar intrahepatic biliary duct dilation (IHBRD), a pseudoaneurysm, and a sub-hepatic collection. In order to relieve these complaints, pigtail catheter drainage was performed. Despite these interventions, the patient presented with persistent jaundice. During the third ERCP, haemobilia was noted in the CBD. Later, contrast-enhanced CT was done, showing rupture of the hepatic artery pseudoaneurysm into the CBD through a small fistulous tract. Later on an emergency basis, exploratory laparotomy was performed to stabilise the patient.

The treatment of pseudoaneurysms typically involves the occlusion of the feeding vessel or pseudo sac through the use of embolic agents. Stents may be considered in cases where pseudoaneurysms are associated with hepatic artery stenosis. However, in situations where embolisation was proved to be unsuccessful, surgical intervention or exploratory laparotomy becomes necessary [4].

Iatrogenic pseudoaneurysm, although rare, is a potentially fatal complication and a high-level clinical suspicion, especially when post-cholecystectomy status patients present with symptoms of abdominal pain, hemobilia, and upper gastrointestinal bleeding.