Vascular emergencies in cholelithiasis and
cholecystectomy: our experience with
two cases and literature review
Narasimhaiah Srinivasaiah, Maneesh Bhojak, Ralph Jackson and Sean Woodcock
Tyne and Wear, UK
BACKGROUND: Complications from gallstones and
KEY WORDS: laparoscopic cholecystectomy;
laparoscopic cholecystectomy can be serious and fatal if there
is a delay in recognition and treatment. We aim to present
two unusual, life threatening vascular complications as a
result of gallstones and laparoscopic cholecystectomy. Their
management is highlighted with a brief review of literature.
METHODS: Data for the article were gathered from
clinical case note review. Radiology database was used for
images. A brief literature review was undertaken using
Hematemesis and melena arising from the
biliary tract was first described by Owen in
Pubmed search. The keywords used included hemobilia,
1848 and termed hemobilia by Sandblom
pseudoaneurysm, arterio-biliary fistula and laparoscopic
1948. Pseudoaneurysm of the hepatic artery
causing arteriobiliary fistula and hemobilia is well
RESULTS: The article highlights two individual case
documented. Diagnosis may be difficult to establish
reports. The first case constitutes an 81-year woman who
had cystic arterial erosion causing hematemesis, while
with fatal consequences.
the second patient was a 57-year man who presented with
We present two unusual life-threatening vascular
hemobilia from a pseudoaneurysm of right hepatic artery
complications resulting from gallstones and laparoscopic
(RHA) following laparoscopic cholecystectomy. Cystic
cholecystectomy. An attempt has been made to increase
arterial erosion was treated with subtotal cholecystectomy
the awareness of choledochoduodenal fistula with
with duodenal defect closure while the pseudoaneurysm
cystic arterial erosion and also giant pseudoaneurysm
underwent radiological intervention.
of the right hepatic artery, secondary to a laparoscopic
CONCLUSIONS: Cystic artery erosion and pseudoaneurysm
cholecystectomy presenting as a near fatal hemobilia
causing arteriobiliary fistula are rare vascular complications
treated by radiological intervention. A brief literature
related to the biliary tree. A high index of suspicion and
review is presented.
timely intervention is important. Trauma to arteries should
be avoided during laparoscopic cholecystectomy.
(Hepatobiliary Pancreat Dis Int 2008; 7: 217-220)
Case 1: Cystic arterial erosion and hematemesis
An 81-year-old woman had calculus cholecystitis with
a common bile duct stone. An ERCP was unsuccessful.
She presented with left basal pneumonia 10 weeks later.
Two days after admission, she developed mild epigastric
Author Affiliations: Department of Surgery, North Tyneside General
pain and significant hematemesis. The epigastric pain
Hospital (Srinivasaiah N and Woodcock S), and Department of
worsened with radiation to both the sides of the upper
Radiology, Freeman Hospital (Bhojak M and Jackson R), Tyne and
abdomen. Further hematemesis led to hemodynamic
instability. The patient was resuscitated and transferred
Corresponding Author: Narasimhaiah
Surgical Unit, Castle Hill Hospital, Cottingham, East Yorkshire HU16
to high dependency unit. Oesophago-gastro-duo-
5JQ, UK (Tel: 0044-7769775552; Email: firstname.lastname@example.org)
denoscopy (OGD) showed a field full of blood making
© 2008, Hepatobiliary Pancreat Dis Int. All rights reserved.
it impossible to locate the source of bleeding.
Hepatobiliary Pancreat Dis Int，Vol 7，No 2 • April 15，2008 • www.hbpdint.com • 217
Hepatobiliary & Pancreatic Diseases International
The patient had laparotomy, which showed
fatal hematemesis, melena and was hemodynamically
adhesions in the right upper quadrant of the abdomen.
unstable. Following resuscitation he was transferred
Gallbladder contained a single stone, with no obvious
source of bleeding. Gallbladder was mobilized
Angiography showed a subtle pseudoaneurysm
revealing an active cystic arterial bleeding which was
arising from the right hepatic artery adjacent to two
spurting into the second part of the duodenum. The
surgical clips. Embolisation of the distal and proximal
patient had subtotal cholecystectomy, duodenal defect
ends revealed that there were more than one bleeding
closure, and feeding jejunostomy. Her recovery was
point, requiring embolization of the whole right
uneventful and was discharged home 49 days later.
hepatic artery. Follow up ultrasound on day 2 and day
5 demonstrated regression of the pseudoaneurysm.
Case 2: Pseudoaneurysm of the right hepatic
The patient was discharged home and is doing well.
artery and hemobilia
A 57-year-old man underwent a cholecystectomy
in acute phase. Four weeks after cholecystectomy,
he presented with right sided abdominal pain and
Hematemesis and melena arising from the biliary
hematemesis. Investigations revealed raising liver
tract are not uncommon. Some of the causes for
function tests (LFTS). Ultrasound scan revealed a
hemobilia are sub-capsular liver injury, trauma,
5-cm aneurysm in the gallbladder bed (Fig. 1). He was
extra- or intra-hepatic aneurysms of the hepatic
transferred to a tertiary centre for intervention.
artery or of its branches, extra- or intra-hepatic
Further imaging with a CT demonstrated an
tumors of the biliary tract,[5-8] gallstone disease
aneurismal sac of 6.9 cm (Fig. 2). The sac was slow
and cholecystitis,[5, 9, 10] Bouveret's syndrome[11, 12]
to fill with contrast and the feeding vessel could
endoscopic retrograde sphincterotomy for choledocho-
not be clearly visualized. A possibility of a cystic
lithiasis,[13, 14] and gallstones causing cholecysto-
artery stump or right hepatic artery aneurysm was
duodenal fistulae. However, to our knowledge there
suspected. Meanwhile the patient developed near
is only one report of a cystic artery ulceration with
cholecystoduodenal fistula causing hematemesis.
Gallstone causing cholecystoduodenal fistula with
cystic arterial transection and active bleeding into the
gastrointestinal tract is a rare occurrence which has to
be borne in mind when dealing with gastrointestinal
Pseudoaneurysms can be associated with the
inflammatory reaction seen with acute cholecystitis[17-19]
or as a result of trauma to the cystic, hepatic and
cholecystectomy.[20-27] Rarely pseudoaneurysms of the
abdominal aorta have also been described secondary
Fig. 1. Ultrasound showing a 5-cm aneurysm in the gallbladder
to laparoscopic cholecystectomy.[28, 29] Other causes of
pseudoaneurysms include plastic biliary stents and
In addition to hemobilia, pseudoaneurysms can
cause hemoperitoneum[20, 32] and can also rupture
into the gallbladder. The treatment modalities for
pseudoaneurysms include coil embolization,[20, 34-36]
ligation of the aneurysm and even percutaneous
thrombin injection has been tried with minimal
Hematemesis and hemobilia are rare vascular
complications associated with a common condition
of cholelithiasis and cholecystectomy. Although rare
they can be life-threatening leading to significant
Fig. 2. CT demonstrating an aneurismal sac of 6.9 cm.
morbidity and mortality.
218 • Hepatobiliary Pancreat Dis Int，Vol 7，No 2 • April 15，2008 • www.hbpdint.com
Vascular emergencies in cholelithiasis and cholecystectomy
In conclusion, gallstones eroding cystic artery
Roche A, et al. Management of clinically relevant bleeding
and pseudoaneurysm causing arteriobiliary fistula
following endoscopic sphincterotomy. Endoscopy 1994;26:
are rare complications of gallstones and laparoscopic
15 Kosugi S, Tani T, Kurosaki I, Hatakeyama K. Gallstone
cholecystectomy, respectively. Although rare cystic
ileus with cholecystoduodenal fistula presenting massive
arterial erosion should be considered as one of the
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differential diagnosis for hematemesis. A high index
of suspicion and timely intervention is important in
16 Guillon P, Benoit J, Champault G, Boutelier P. A rare
patients who present with hematemesis or hemobilia.
complication of cholelithiasis. Ulceration of the cystic
Needless to say, trauma to arteries should be avoided
artery associated with cholecystoduodenal fistula. J Chir
during laparoscopic cholecystectomy in order to
17 Maeda A, Kunou T, Saeki S, Aono K, Murata T, Niinomi
prevent pseudoaneurysms causing arteriobiliary
N, et al. Pseudoaneurysm of the cystic artery with
hemobilia treated by arterial embolization and elective
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18 Akatsu T, Tanabe M, Shimizu T, Handa K, Kawachi
Ethical approval: Not needed.
S, Aiura K, et al. Pseudoaneurysm of the cystic artery
Contributors: SN and BM proposed the study, collected and
secondary to cholecystitis as a cause of hemobilia: report
summarized the data. SN wrote the first draft, corrected by both
of a case. Surg Today 2007;37:412-417.
JR & WS. All authors contributed to the intellectual context and
19 Saluja SS, Ray S, Gulati MS, Pal S, Sahni P, Chattopadhyay
approved the final version. SN is the guarantor.
TK. Acute cholecystitis with massive upper gastrointestinal
Competing interest: No benefits in any form have been received
bleed: a case report and review of the literature. BMC
or will be received from a commercial party related directly or
indirectly to the subject of this article.
20 Madanur MA, Battula N, Sethi H, Deshpande R, Heaton
N, Rela M. Pseudoaneurysm following laparoscopic
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Received October 8, 2007
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Accepted after revision December 30, 2007
In the article entitled Chronic pancreatitis: a sequela of acute fatty liver of pregnancy by Apiratpracha et
al (Hepatobiliary Pancreat Dis Int 2008;7:101-104.), the name of the third author should be Charles H.
220 • Hepatobiliary Pancreat Dis Int，Vol 7，No 2 • April 15，2008 • www.hbpdint.com