A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula

Abstract

INTRODUCTION Cystic artery pseudoaneurysms and cholecystoenteric fistulae represent two rare complications of gallstone disease. PRESENTATION OF CASE An 86 year old male presented to the emergency department with obstructive jaundice, RUQ pain and subsequent upper gastrointestinal bleeding. Upper GI endoscopy revealed bleeding from the medial wall of the second part of the duodenum and a contrast-enhanced computed tomography scan revealed a cystic artery pseudoaneurysm, concurrent cholecystojejunal fistula and gallstone ileus. This patient was successfully managed surgically with open subtotal cholecystectomy, pseudoaneurysm resection and fistula repair. DISCUSSION To date there are very few cases describing haemobilia resulting from a bleeding cystic artery pseudoaneurysm. This report is the first to describe upper gastrointestinal bleeding as a consequence of two synchronous rare pathologies: a ruptured cystic artery pseudoaneurysm causing haemobilia and bleeding through a concurrent cholecystojejunal fistula. CONCLUSION Through this case, we stress the importance of accurate and early diagnosis through ultra- sonography, endoscopy, and contrast-enhanced CT imaging and emphasise that haemobilia should be included in the differential diagnosis of anyone presenting with upper gastrointestinal bleeding. We have demonstrated the success of surgical management alone in the treatment of such a case, but accept that consideration of combined therapeutic approach with angiography be given in the first instance, when available and clinically indicated.

Keywords: Cholecystoenteric fistula; Cholecystojejunal fistula; Cystic Artery; Pseudoaneurysm.

Fig. 1

Second part of the duodenum viewed at OGD with a tubular clot adherent to medial wall, likely to be originating from the ampulla of vater.

Fig. 2

Axial computed tomographic images with contrast demonstrating (a) small bowel obstruction secondary to a gallstone impacted in the distal ileum, (b) a thick-walled, inflamed gallbladder with evidence of recent intra-cholecystic bleeding, seen to be originating from (c) a 12 mm cystic artery pseudoaneurysm. This cystic artery pseudoaneurysm was further defined on CT angiography (d).