Lower gastrointestinal bleeding due to hepatic artery pseudoaneurysm following laparoscopic cholecystectomy.

Pseudoaneurysm of hepatic artery is a rare but known complication of laparoscopic cholecystectomy (LC). Such pseudoaneurysms may bleed in biliary tree, upper gastrointestinal (GI) tract or peritoneal cavity leading to life-threatening internal haemorrhage. It is very rare for them to present as lower GI bleeding. We report an unusual case of Right hepatic artery pseudoaneurysm developed following LC, which ruptured into hepatic flexure of colon resulting in catastrophic lower GI bleeding. This was associated with partial celiac artery occlusion due to thrombosis. Due to failure of therapeutic embolisation, the patient was subjected to exploratory laparotomy to control haemorrhage. Postoperatively, patient recovered well and was discharged on postoperative day 10. A strong index of suspicion is necessary for early diagnosis of such condition and to limit resultant morbidity. Angioembolisation is the first-line treatment and surgery is indicated in selected cases.

INTRODUCTION

Laparoscopic cholecystectomy (LC), as compared to open procedure, has higher incidence of biliary and vascular injuries (0.3–1.0%).[1] Pseudoaneurysm formation is an uncommon but known complication of such injuries.[2] It is still rare for such lesions to bleed into lower gastrointestinal (GI) tract and present as haematochezia.

CASE REPORT

A 45-year-old male patient presented with pain in right upper quadrant of abdomen. Ultrasound of abdomen showed cholelithiasis and choledocholithiasis for which patient underwent ERCP and stenting with stone extraction. Three weeks later, patient was subjected to LC. Intraoperative course was uneventful except for minor bleeding at Calot's triangle which was successfully cauterized. Early postoperative course was uneventful and patient was discharged on postoperative day 3. After 15 days of discharge, patient presented in the emergency with giddiness and history of haematochezia since 2 days. On examination, he was hypotensive and pale. Per rectal examination showed fresh blood with no local pathology. Ryle's tube aspirate was bilious. Oesophagogastroduodenoscopy did not reveal any evidence of upper GI bleeding. CT angiography suggested active bleeding from a pseudoaneurysm into sub-hepatic space [Figure 1]. Triple-vessel conventional angiography revealed pseudoaneurysm of right hepatic artery [Figure 2]. However, embolisation was not successful due to partial thrombosis at celiac artery origin.

Figure 1

CT angiography—contrast extravasation into right sub-hepatic space

Figure 2

Right hepatic artery pseudoaneurysm on conventional angiography

Hence, an emergency laparotomy was contemplated. An actively bleeding right hepatic artery pseudoaneurysm and its fistulous communication with hepatic flexure of the colon were found [Figure 3]. The bleeding aneurysmal vessel was ligated. In view of poor general condition and intraoperative hemodynamic instability, the site of fistulous communication on colon was freshened and brought out as loop colostomy. Postoperative course was uneventful. Patient was discharged on postoperative day 10 and is doing well on follow-up.

Figure 3

(a) Ligated right hepatic artery pseudoaneurysm and (b) opening in hepatic flexure of colon

DISCUSSION

Vascular injuries occur in upto 0.8% of cases following LC. In the presence of a bile duct injury upto 25% will have a concomitant vascular injury.[1] Most of the vascular injuries present as intraoperative bleeding. While most of vascular injuries present as intraoperative bleeding, rarely minor injury to the vessel may go unrecognised and present later as a pseudoaneurysm.[3] Review of literature reveals 54 cases of cholecystectomy-related pseudoaneurysms.[2]

Possible mechanisms of vascular injury during LC could be direct injury due to dissection, use of diathermy leading to direct trauma or accentuated conduction through the surgical clips (as may have occurred in our case), vascular erosions due to encroachment by metal clips or sepsis and inflammation secondary to biliary injury and bile leak causing damage to the vascular wall.[13] Common sites of injury are right hepatic artery (61% cases), common hepatic and cystic artery.[2] These kinds of injuries can be avoided by taking simple precautions like careful usage of diathermy near the metal clips in the cystic duct or cystic artery and staying close to the gallbladder wall during dissection of the Calot's triangle.[1] Abdominal trauma, percutaneous liver biopsy, liver transplantation, pancreatitis, etc. are other known causes of hepatic artery pseudoaneurysm.[4]

In majority of patients, hepatic artery pseudoaneurysms are asymptomatic.[4] Symptoms may appear in the early postoperative period or as late as 120 days after operation.[1] Common presentations are right upper quadrant pain, jaundice, altered liver function tests and rupture with internal haemorrhage.[5] The risk of rupture is high about 80% with associated mortality rate of upto 50%. Common sites of bleeding are biliary and upper GI tract or peritoneum leading to hypovolemic shock, GI haemorrhage, biliary colic, haemobilia or obstructive jaundice.[4] Pseudoaneurysm bleeding in lower GI tract presenting as haematochezia, as in our case is extremely rare. There is only one such incident reported in the literature by Dr. R.S. Mohil et al. which was following abdominal trauma.[4] Rupture of a pseudoaneurysm into the peritoneal cavity may present as acute cardiovascular collapse or be temporally contained by surrounding tissue, which is often called ‘double rupture phenomenon’.[2]

A high index of suspicion is necessary for diagnosis in patients presenting with GI haemorrhage following LC. CT scan of abdomen with CT angiography may aid diagnosis by demonstrating haemorrhage or pseudoaneurysm. However, most reliable diagnostic test is triple-vessel conventional angiography.[3]

First line of treatment in hepatic artery pseudoaneurysm is angioembolisation.[2] Surgery is indicated if there is failure of angioembolisation, hemodynamic instability, compression of bile duct or fistula.[1] Failure of angioembolisation was indication of surgery in our case. Several surgical options such as primary repair, patch angioplasty, saphenous vein or graft interposition are available.[2] However, surgeon might decide to ligate the artery if repair is not feasible as in our case. Surgical ligation carries a 20–29% complication rate and a mortality rate of upto 50% in unstable patients.[4] Review of literature showed that in 82% cases embolization was successful, while 18% required surgery.[2]

To conclude, hepatic artery pseudoaneurysm after LC is a rare but recognized and potentially fatal complication. Hence, main concern is the prevention of the iatrogenic injury. A high index of suspicion is warranted in patients who present with lower GI bleeding following LC. Angioembolisation is the treatment of choice. Surgery, though morbid, is life saving in cases of failure of angioembolisation.