Hemorrhage into the gallbladder caused by pseudoaneurysm of the cystic artery

A 77-year-old woman was admitted to hospital with cholecystitis. After 8 days of antibiotic treatment she developed hypotension, weakness, and anemia. Abdominal computed tomography showed a tense gallbladder containing blood and a round nodule which enhanced after administration of contrast material (Figure [1]). Doppler ultrasonography showed a nodule with arterial flow and a “ying yang” pattern (Figure [2]), and selective angiography revealed an cystic artery pseudoaneurysm (Figure [3]). Metallic coils were used as embolization material and full occlusion of the aneurysmal sac was achieved.

Figure 1 Abdominal computed tomography showed blood and a nodule in the gallbladder.

Figure 2 Doppler ultrasonography showed a nodule with a “ying yang” pattern.

Figure 3 Selective angiography revealed a cystic artery pseudoaneurysm (arrow).

Hemorrhage into the gallbladder occurs rarely and can result from gangrenous cholecystitis, cystic artery pseudoaneurysm, varicose veins in the gallbladder wall, or tumors [1]. In this case hemorrhage was caused by a pseudoaneurysm. Cystic artery pseudoaneurysms can form secondary to atherosclerosis, or can follow trauma; they can also arise as a result of arterial wall erosion by local inflammatory processes such as cholecystitis [2] [3]. The diagnosis is difficult but it may be suggested by abdominal computed tomography and Doppler ultrasonography. Angiography allows for both a definitive diagnosis and simultaneous therapeutic intervention [4].

Endoscopy_UCTN_Code_CCL_1AZ_2AN

References

• 1 Berland L L, Doust B D, Foley W D. Acute hemorrhage into the gallbladder diagnosed by computed tomography and ultrasonography.  J Comput Assist Tomogr. 1980;  4 260-262
• 2 Gutierrez C, Ramia J M, Villar J. et al . Cystic artery pseudoaneurism from an evolved acute calculous cholecystitis.  Am J Surg. 2004;  187 519-520
• 3 Siablis D, Papathanassiou Z G, Karnabatidis D. et al . Hemobilia secondary to hepatic artery pseudoaneurysm: an unusual complication of bile leakage in a patient with a history of a resected IIIb Klatskin tumor.  World J Gastroenterol. 2005;  11 5229-5231
• 4 Moodley J, Singh B, Lalloo S. et al . Non-operative management of haemobilia.  Br J Surg. 2001;  88 1073-1076