Trevor L Schell1, Patrick Hoversten2, Eric Gaumnitz2. 1. University of Wisconsin School of Medicine and Public Health, Department of Medicine, Madison, WI. 2. University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Gastroenterology and Hepatology, Madison, WI.
A 73-year-old man presented to the emergency department with 2 weeks of melena and was found to have blood loss anemia with hemoglobin 5.6 g/dL. The patient underwent laparoscopic cholecystectomy 2 months earlier. Esophagogastroduodenoscopy revealed a possible submucosal lesion vs a region of extrinsic compression in the duodenum with an overlying focal area of oozing erosion (Figure 1). One hemostatic clip was placed, and the lesion was biopsied using a bite-in-bite technique. Abdominal computed tomography revealed a collection of high-attenuation material within the biliary fossa, adjacent to the duodenum and hemostatic clip (Figure 2). Given concern for a vascular lesion, abdominal computed tomography angiogram was obtained, which revealed a 7 cm cystic artery stump pseudoaneurysm (CAP) exerting mass effect on the duodenum (Figure 3). Angiography with coil embolization and ultrasound-guided percutaneous thrombin injection was performed; bleeding resolved; and the patient was discharged without evidence of complication to date (Figure 4). Duodenal biopsies demonstrated normal duodenal mucosa. CAP is a very rare complication of cholecystectomy and is an even rarer cause of upper gastrointestinal bleeding.[1] This case demonstrates the importance of early recognition in the management of CAP complicated by upper gastrointestinal bleeding, being that the preferred therapeutic approach is endovascular as opposed to endoscopic.
Figure 1.
Esophagogastroduodenoscopy demonstrating a duodenal lesion with overlying erosion, which was subsequently clipped and biopsied with a bite-in-bite technique.
Figure 2.
Abdominal computed tomography showing a collection of high-attenuation material within the biliary fossa, adjacent to the duodenum and hemostatic clip.
Figure 3.
computed tomography angiogram demonstrating a 7 cm cystic artery stump pseudoaneurysm with mass effect on the duodenum.
Figure 4.
Angiography showing contrast filling of a large pseudoaneurysm within the gallbladder fossa, adjacent to numerous surgical clips.
Esophagogastroduodenoscopy demonstrating a duodenal lesion with overlying erosion, which was subsequently clipped and biopsied with a bite-in-bite technique.Abdominal computed tomography showing a collection of high-attenuation material within the biliary fossa, adjacent to the duodenum and hemostatic clip.computed tomography angiogram demonstrating a 7 cm cystic artery stump pseudoaneurysm with mass effect on the duodenum.Angiography showing contrast filling of a large pseudoaneurysm within the gallbladder fossa, adjacent to numerous surgical clips.
DISCLOSURES
Author contributions: TL Schell wrote the manuscript, edited the manuscript, reviewed the literature, revised the manuscript for intellectual content, and approved the final manuscript. P. Hoversten edited the manuscript, provided the images, revised the manuscript for intellectual content, and approved the final manuscript. E. Gaumnitz edited the manuscript, revised the manuscript for intellectual content, approved the final manuscript, and is the article guarantor.Financial disclosure: None to report.Previous presentation: Not applicable.Informed consent was obtained for this case report.
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Figure 4.