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Year 2017 / Volume 109 / Number 8
Digestive Diseases ImageHemobilia due to a cystic artery pseudoaneurysm on ultrasound587-588Victoria de Lara Bendahán, Encarna García DomÍnguez, Marta Rivas Rivas, Jesús García SerranoThe present paper describes a case of hemobilia in a woman with a cystic artery pseudoaneurysm.The pseudoaneurysm could be seen with ultrasound, Doppler sonography and CT angiography. In ourcase, Doppler sonography was the most useful technique for diagnosis, revealing the turbulentforward and backwards flow within the gallbladder, representing the focally dilated artery. This waslater confirmed by CT angiography. A recent bleeding site was found on the cholecystectomyspecimen.
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IPD 4936 inglés
Hemobilia due to a cystic artery pseudoaneurysm on ultrasound
Victoria De-Lara-Bendahán1, Encarna García-Domínguez2, Marta Rivas-Rivas2 and Jesús
García-Serrano1
Clinical Management Unit of 1Radiodiagnosis and 2Digestive Diseases. Hospital
Universitario de Puerto Real. Cádiz, Spain
Correspondence: Victoria de Lara Bendahán
e-mail: [email protected]
CASE REPORT
An 85-year-old woman with a history of gallbladder stones presented with epigastric
pain and vomiting. Blood chemistry showed: GGT 350, AP 215, bilirubin 3.4 (direct 2.6)
and CRP 2.11. Ultrasound revealed a thickened gallbladder with a stone, echogenic bile
and a 3-cm intravesical collection around the calculus (Fig. 1). Doppler examination
showed bidirectional vascular flow expressed as two different colors within the
intravesical collection (Fig. 2).
Later she presented with melena, which prompted an endoscopic retrograde
cholangiography procedure that resulted in bleeding and clot removal. An angio-CT
scan was performed due to the suspicion of hemobilia due to a pseudoaneurysm
complicating calculus cholecystitis. The scan showed a dilated cystic artery with a
pseudoaneurysm (Fig. 3). The laparoscopic cholecystectomy specimen had a recent
bleeding site.
DISCUSSION
Cystic artery pseudoaneurysm is a rare, usually iatrogenic cause of hemobilia (1),
although cases secondary to cholecystitis have been reported (2). Arterial wall erosion
from inflammation may cause its development (2).
Ultrasound may identify the focally dilated artery as a collection within the gallbladder
(3). Doppler ultrasound revealed bidirectional vascular flow which is a mix of two
colors due to the turbulent flow inside the pseudoaneurysm. This is known as the “yin-
yang sign” due to its similarity with the Asian symbol (3). CT angiography or
arteriography demonstrated the focally dilated artery (1). However, doppler
ultrasound was the most useful study to confirm the suspicion in a rapid, effective,
non-invasive manner in our case.
REFERENCE
1. Asad Ali, Sofronis Loizides, Richard Newton, et al. Laparoscopic management of
a cystic artery pseudoaneurysm in a patient with calculus cholecystitis. Int J Surg Case
Rep 2015;14:182-5. DOI: 10.1016/j.ijscr.2015.08.007
2. De Quinta Frutos R, Moles Morenilla L, Docobo Durantes F, et al. Hemobilia
secondary to chronic cholecystitis. Rev Esp Enferm Dig 2004;96:221-5. DOI:
10.4321/S1130-01082004000300009
3. Badano F. Signo del Yin-Yang. Rev Arg Radiol 2010;74:403-5.
Fig. 1. Gallbladder with a thickened wall from inflammatory changes, echogenic bile
contents that looked like blood (hemobilia) or sludge and a hyperechogenic stone with
a posterior acoustic shadow (thin arrow). An anechoic oval image corresponding to a
3-cm collection around the calculus (thick arrow) was also seen which represented the
cystic artery pseudoaneurysm, a condition unsuspected with ultrasound alone.
Fig. 2. Doppler ultrasound revealing vascular flow within the lesion surrounding the
stone. The flow was bidirectional, both anterograde and retrograde, as represented by
the two colors (thick arrow). This hemodynamic disturbance shape is typical of vascular
lesions such as pseudoaneurysms, and is known as the “yin-yang” sign due to the
similarity with the well-known Asian symbol.
Fig. 3. Angio-CT scan showing a 3-cm sac-like structure filled with intravenous contrast,
indicating its vascular origin within the gallbladder (arrow). It communicates with the
cystic artery and represents the arterial pseudoaneurysm.