- Case report
- Open Access
- Open Peer Review
Delayed hemobilia due to hepatic artery pseudo-aneurysm: a pitfall of laparoscopic cholecystectomy
© The Author(s). 2016
- Received: 16 April 2016
- Accepted: 10 August 2016
- Published: 22 August 2016
Hepatic artery pseudoaneurysm as a complication of laparoscopic cholecystectomy is considered a rare, potentially life threatening condition.
We report a case of late onset hemobilia presenting 8 months following elective laparoscopic cholecystectomy with complex biliary and vascular injury. The patient was treated surgically with primary repair of the aneurysm and hepaticojujenostomy.
A high index of suspicion should be raised when encountering a patient with massive upper GI bleeding and a previous history of hepatobiliary manipulation or surgery regardless of postoperative period.
- Hepatic Artery
- Laparoscopic Cholecystectomy
- Common Hepatic Artery
- Biliary Injury
- Elective Laparoscopic Cholecystectomy
Summary of similar cases (post laparoscopic cholecystectomy hepatic artery pseudoaneurysm) reported in the literature
Time of presentation
Genyk YS 
Pain, UGIB and jaundice.
2 year follow up
Jean-Denis Yelle, et al. 
Contrast study of the fistula, ERCP& HPA
Siablis D, et al. 
Pain, jaundice and UGIB.
Close follow ups
Sam T.M. Kwauk, et al. 
N\V, pain and jaundice.
CT and HPA
Ribeiro A, et al. 
UGI endoscopy, CT and HPA
de Blaauw I, et al. 
Pains and melena
T nicholoson et al. 
Well at 15 month
Well at 5 years
Well at 7 years
Well at 4 years
Well at 6 years
Well at 3 years
Well at 5 years
Well at 2 years
Well at 6 years
Dogru O, et al. 
Ultrasound and UGI endoscopy
Iannelli A et al., ,
G Roche-Nagle, et al. 
Pain, and vitally collapsed
CT & HPA
Mandur Ma et al. ,
Well at 22 month
Well at 12 month
Well at 6 months
Nakase Y, et al. 
Pain and UGIB
Masannat YA 
Srinivasaiah N 
Pain and hematemesis
Ultrasound, CT and HPA
Yao CA, et al. 
Pain, UGIB, and disturbed LFTs.
Angiography with embolization
Sansonna et al., 
Angiography with embolization
Well at 2 weeks
Paseka T et al., 
CT & HPA.
Well at 6 months.
AD Mate et al., 
El Bouhaddouti, et al. 
Pain, jaundice and UGIB
UGI endoscopy & HPA
Thamer A. Bin Traiki et al. 
Febrile (38.9 °C, (left brachial vein Thrombosis).
CT, ERCP, & HPA.
Angiography and embolization.
well at discharge
Tun-Abraham ME et al., 
Biliary leakage, sepsis and late intra-abdominal bleeding
Angiography with embolization
No evidence of recurrent bleeding
Abdallah S et al., 
Obstructive jaundice and pain
CT & HPA.
Chih yang Hsiao et al., 
Jaundice, pain and oozing blood from drainage.
MR & HPA.
Embolization and angiography.
A 41-year-old female patient presented to our emergency department with history of upper gastrointestinal (UGI) bleeding in the form of painless coffee ground vomitus and melena. Patient has no significant past medical history apart from uneventful elective laparoscopic cholecystectomy due to a remote episode of acute cholecystitis in another institution 8 months prior to her presentation. Upon reviewing the patient’s charts, the operation was smooth, no intraoperative complications encountered, monopolar cautery energy source was used and no intraoperative cholangiogram was obtained.
The patient had history of previous attack of minimal UGI bleeding 6 weeks post cholecystectomy, at that time an upper endoscopy and ERCP were done showing hemobilia, and a stent was placed in the common bile duct. Following that, the patient was relieved of symptoms and a CT study confirmed the presence of a small (<0.25 cm) right hepatic artery pseudoaneurysm. The patient was offered the option of embolization, however she refused the treatment and lost follow up until the current presentation.
Upon her presentation to our center, the patient was pale, tachycardiac (100–110 bpm) and normotensive. Abdomen was soft and lax with no sign of peritonitis were noted upon palpation.
Hemoglobin: 10.3 g\L, Hematocrit: 33, Platelets: 44 × 109/L. Coagulation profile was normal and Liver function showed a mild elevation of the liver enzymes.
Roux-en-y hepatico-jujenostomy was performed. The stent has migrated and it was felt in the transverse colon, it was retrieved through a colotomy.
The patient had an uneventful recovery apart from wound infection. Her LFT gradually returned back to normal levels. After discharge the patient had been followed up for 14 months with no evidence of reoccurrence of bleeding.
Laparoscopic cholecystectomy (LC) carries the risk of biliary and vascular iatrogenic injuries even in the hands of most experienced surgeons. Despite its many benefits in comparison to open procedure it carries a 10-fold increased risk of iatrogenic biliary and vascular injuries . Laparoscopic biliary tree injuries are reported in 0.3–1 % of procedures, whereas vascular injuries reported in 0.25–0.5 % (7–9). It is well known in the literature that intraoperative bleeding is the most common manifestation of LC iatrogenic arterial injury followed by ligation. A less common manifestation of post LC iatrogenic arterial injury is presented here.
Approximately 10 % of all the reported cases of hemobilia are secondary to iatrogenic hepatic artery pseudo-aneurysms (Table 1) (8).
Upper GI hemorrhage is the most common presentation of a ruptured right hepatic artery pseudo-aneurysm into the biliary tract. However, the classic presentation of hemobilia known as Quinke’s triad is seen in less than 40 % of patients [1, 6, 7].
To date, the definite pathological explanation of post LC hemobilia is still unclear but suggested mechanisms are mechanical, thermal injuries specially monopolar coagulation during laparoscopic surgeries and surgical clips encroachments [8–10]. Bile leak and superimposed infection are important precipitating factors, It has been reported that bile acid could contribute to the injury to the vascular wall resulting in delayed healing of the vessel wall which leads to the development of pseudoaneurysm . We believe the mechanism of injury in our patient is thermal, due to the presence of vascular and biliary injuries and her delayed presentation.
There are several options for diagnosing and managing such condition, Upper gastrointestinal endoscopic evaluation is fundamental to exclude the more common causes of UGI bleeding . In the current Literature nearly 12 % of cases reported diagnosed endoscopically .
Contrast enhanced computed tomography of the abdomen aids in determining the diverse etiological causes of the hemobilia . The difficulty in making the diagnosis of hemobilia might be attributable to the fact that the bleeding is usually intermittent.
The management of hemobilia is an acute emergency as patient might exsanguinate when ruptured. The therapeutic aim is to stop the bleeding and to relive biliary obstruction . Transarterial embolization (TAE) is the treatment choice for all causes of hepatic artery aneurysm with a high rate of success, surgical intervention should be done for selected patients who fail a trial of embolization (12) as in our case. Angiography offers the advantage of minimally invasive procedure, and it also represents an effective treatment choice for this potentially fatal complication [15, 16].
The time phase between confirming the diagnosis of hemobilia and the decision for surgical intervention in case of absence or failure of embolization is crucial and must be managed meticulously by the attending surgeon. As these patients are at risk of sudden rupture and exsanguination.
A high index of suspicion should be considered by all treating surgeons when encountering instances of hemobilia in patients presenting with upper GI hemorrhage with a past history of cholecystectomy regardless of the post-operative period. Assessment of the hepatic arteries is an important aspect of the investigation of all biliary injuries. Intraoperative preventive measures are paramount in preventing these complications, such as careful dissection and the avoidance of cautery usage adjacent to the vasculo-biliary structures during LC.
The authors declare that they have no financial interest to declare in relation to the content of this article.
Availability of data & material
All data and material presented in the article are available upon request.
MA: literature review and summarized all previous similar cases, wrote part of introduction and discussion. AN: wrote the case details and clinical coarse, improved the introduction and photography. RJ: surgeon who performed vascular repair in the case, reviewed the whole manuscript, offered critiques and improved the discussion. YQ: reviewed the whole manuscript, offered critiques and improved the discussion. MA: surgeon who performed the operation, reviewed the case, wrote part of discussion and introduction. All authors read and approved the final manuscript.
The authors declare that they have no competing interests. All authors agree to the terms of the Biomed Central Copyright and License.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor of this journal.
Ethics approval and consent to participate
This case report was approved by King Abdulaziz University Hospital ethical committee.
The authors declare no conflict of interest in the work to produce this article.
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