Radiology

Case Report:

A forty-year-old woman underwent cholecystectomy and common bile duct exploration for the same biliary calculus disease. Following the surgery, a T-tube was placed in CBD and a drainage tube placed in the Morison’s pouch. Eighteen days later she presented with one episode of hemetemesis and malena and passage of blood clots in the T-tube and colostomy bag. No bruit was present in abdomen. Although she was clinically stable her hemoglobin level had dropped to 7.2gm% as compared to the normal preoperative values.

Because of the persistent symptoms, upper GI endoscopy was performed which revealed blood clots in the fundus of the stomach with gastric erosions. US of the abdomen demonstrated perichodochal collection. A T-tube cholangiogram did not show any extravasation of contrast. The celiac angiogram is shown in Fig 1.

Fig 1

 

Fig 2

These reveal a saccular pseudoaneurysm arising from the right hepatic artery branch with no evidence of arteriovenous or arteriobiliary fistula.

A superselective right hepatic arteriogram confirms to better advantage the presence of a pseudoaneurysm

Fig 3

Selective coil embolization of the segmental right hepatic artery branch was done with tungsten coils (BALT SPI-2-60P). Post procedure check angiogram showed embolisation of feeding branch with complete obliteration of aneurysm.

Fig 4

The patient recovered uneventfully with resolution of hemetemesis and hemobilia over the next two days.

Discussion:

In 50% of cases of hemobilia, bleeding originates from the liver parenchyma, whereas the biliary ducts and the gall bladder are the source in approximately 45% of the cases. Hemobilia due to pancreatic disease is rare.

The hepatic artery is the fourth most common site of an intra-abdominal aneurysm from any cause following the infrarenal aorta, iliac and splenic vessels. The majority (80%) of true hepatic artery aneurysms develop in the extra hepatic portion of the vessel and of these, 63% affect the common hepatic artery, 5% the left hepatic, and 4% the right and left hepatic arteries. Intra hepatic aneurysms are almost always false aneurysms related to traumatic disruption of an intraparenchymal artery.

Trauma is by far the most common cause of hemobilia accounting for 50% of the cases; approximately 1/3^rd are iatrogenic which includes diagnostic biopsy and percutaneous transhepatic cholangiography. Another less common cause in this group is post cholecystectomy and surgical manipulation in the biliary tree secondary to mucosal laceration by the instruments. Occasionally bleeding can be due to pseudoaneurysm following surgical exploration

Uncomplicated hepatic artery aneurysms are often asymptomatic, and usually of no clinical significance and subside spontaneously. Symptoms when present, are nonspecific, upper abdominal pain not related to food being the commonest. Quickes triad of symptoms viz. biliary colic, hemobilia and obstructive jaundice is seen in only 33% of cases. GI symptoms include malena or hemetemesis. Additional signs and symptoms include anemia (70% of cases), fever, a palpable mass with or without bruit in the right upper quadrant and dull pain. Another important feature is the time lag between the initial injury and the evidence of subtle bleeding and recurrence of hemorrhage, which may be present for weeks, months, or years.

The diagnosis of hemobilia is difficult unless the condition is suspected. PTC or ERCP may show filling defects, but they are not pathognomonic for hemobilia. Ultrasound may reveal a hypoechoic, pulsatile mass within the liver with bi-directional flow on Doppler or a dense echogenic intraluminal mass within the gall bladder without acoustic shadowing. Although contrast enhanced CT will not demonstrate the erosive vascular changes as seen on arteriograms, it may demonstrate hemorrhage or pseudoaneurysm formation which may be missed on ERCP and angiogram because of the intermittent character of the bleeding episode.

The most reliable diagnostic test is selective celiac and SMA angiography. The angiographic feature most frequently associated with hemobilia originating in liver and bile ducts is pseudoaneurysm. Hepatic artery-portal vein or hepatic artery-hepatic vein fistulae are other findings. Venobiliary fistulae are rare.

The most serious complication is rupture which has been reported to occur in 60-70% of patients. Rupture may occur into the peritoneal cavity, the biliary tree or the portal venous system with a mortality of at least 50%. Intervention is therefore recommended for hepatic artery aneurysm even in the absence of rupture. Intervention is also required in case of significant hemobilia as it seldom ceases spontaneously.

Treatment modalities include surgery and percutaneous embolization. Aneurysms proximal to the origin of the gastroduodenal artery can be treated by the proximal and distal ligation and excision of the aneurysmal sac. Those distal to this site are managed by reconstructive endoaneuryrmorraphy or excision of the aneurysm and reconstruction with autogenous or prosthetic graft. Transcatheter embolisation has dramatically improved the management of these lesions, enabling nonoperative treatment in situations that once necessitated hepatic resection. A variety of transcatheter methods have been employed including embolisation with absorbable gelatin sponge (gel foam), insertion of Gianturco coils and instillation of thrombin. The primary goal of embolic therapy is to reduce the pulsatile blood pressure distal to artificial occlusion rather than to devascularise the hepatic parenchyma. Peripheral placement of the catheter in the vessel feeding the abnormality and embolisation with absorbable particulate matter seems to be the most effective. However central embolisation of the main hepatic artery or one of its peripheral branches is indicated whenever a peripheral branch can not be cannulated or if the patient’s deteriorating condition mandates prompt intervention. Spring coils or detachable balloon coils can be used for these occlusions. Infarction and necrosis of liver parenchyma usually do not occur with central embolisation because of potential for collateral circulation and dual hepatic vascular supply.

Pseudoaneurysms of the hepatic artery are rare , commonest cause being the iatrogenic. The most reliable diagnostic selective test is selective celiac and SMA angiography. Transcatheter embolisation is an effective method for the treatment of aneurysm of the splanchanic arteries and of hemobilia.

 

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