Vascular emergencies in cholelithiasis and cholecystectomy: our experience with two cases and literature review

Case Report
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
hemobilia;
is a delay in recognition and treatment. We aim to present
hematemesis;
two unusual, life threatening vascular complications as a
pseudoaneurysm
result of gallstones and laparoscopic cholecystectomy. Their
management is highlighted with a brief review of literature.
METHODS: Data for the article were gathered from
Introduction
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[1]  and  termed  hemobilia  by  Sandblom 
pseudoaneurysm, arterio-biliary fistula and laparoscopic
cholecystectomy.
1948.[2]  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 reports
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 
Wear, UK
abdomen.  Further  hematemesis  led  to  hemodynamic 
instability. The patient was resuscitated and transferred 
Corresponding Author: Narasimhaiah 
Srinivasaiah, 
Academic 
Surgical Unit, Castle Hill Hospital, Cottingham, East Yorkshire HU16 
to  high  dependency  unit.  Oesophago-gastro-duo-
5JQ, UK (Tel: 0044-7769775552; Email: simha_anu@yahoo.com)
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

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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 
for angiography.
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, 
Discussion
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,[2]  trauma,[3] 
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,[4]  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.[15] 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.[16] 
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 
bleeding.
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 
gastro-duodenal 
arteries 
during 
laparoscopic 
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 
bed.
pseudoaneurysms  include  plastic  biliary  stents[30]  and 
warfarin overdose.[31] 
In  addition  to  hemobilia,  pseudoaneurysms  can 
cause  hemoperitoneum[20,  32]  and  can  also  rupture 
into  the  gallbladder.[33]  The  treatment  modalities  for 
pseudoaneurysms  include  coil  embolization,[20,  34-36] 
ligation  of  the  aneurysm[32]  and  even  percutaneous 
thrombin  injection  has  been  tried  with  minimal 
success.[32, 37]
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

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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 
217-221.
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 
upper  gastrointestinal  hemorrhage.  J  Gastroenterol 
differential  diagnosis  for  hematemesis.  A  high  index 
Hepatol 2006;21:624-625.
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 
(Paris) 1994;131:250-251.
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 
fistulae. 
hemobilia  treated  by  arterial  embolization  and  elective 
cholecystectomy. J Hepatobiliary Pancreat Surg 2002;9:755- 
758.
Funding: None.
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 
Gastroenterol 2007;7:12. 
indirectly to the subject of this article.
20   Madanur  MA,  Battula  N,  Sethi  H,  Deshpande  R,  Heaton 
N,  Rela  M.  Pseudoaneurysm  following  laparoscopic 
cholecystectomy.  Hepatobiliary  Pancreat  Dis  Int  2007;6: 
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Hepatobiliary & Pancreatic Diseases International
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Correction
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. 
Scudamore. 
220 • Hepatobiliary Pancreat Dis Int，Vol 7，No 2 • April 15，2008 • www.hbpdint.com

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