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

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.

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.

Figure 2

A: Angio-embolization of the pseudoaneurysm with gelfoam and microcoil. B: Post embolization image showing non-filling of the pseudoaneurysm (arrow).