Figure 1
Unenhanced CT abdomen
Hyperdensity in gall bladder suggestive of haemobilia.
Cystic artery pseudoaneurysm presenting as haematemesis
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsSubbarao Chandana, Trupti Dabholkar
Connected authors
81 years, male
Clinical History
81-year-old male patient presented with haematemesis, melaena and epigastric pain. No jaundice / alcohol intake / known malignancy. Gastroscopy showed fresh blood in the stomach.
Imaging Findings
Unenhanced CT abdomen showed abnormal high attenuation in gallbladder suggestive of haemobilia.
CT angiogram revealed a round, homogeneous, well-defined, intensely enhancing 1.6 cm lesion within the gallbladder paralleling the enhancement pattern of the arteries, with the cystic artery feeding it, suggestive of pseudoaneurysm. No active bleeding was demonstrated in the gallbladder, stomach or duodenum.
The gallbladder showed diffuse thickening of the wall with multiple locules of gas in the lumen. Associated pericholecystic inflammatory changes and loss of fat plane between the gallbladder and first part of duodenum were seen, suggestive of cholecystitis with cholecystoduodenal fistula. No dilatation of common bile duct (CBD) or intrahepatic bile ducts was seen.
Ultrasound and colour Doppler revealed thick-walled gallbladder with internal echoes (likely blood). A cystic structure was also seen in the lumen with swirling flow within, confirming the diagnosis of cystic artery pseudoaneurysm. No gallstone was seen.
CT angiogram revealed a round, homogeneous, well-defined, intensely enhancing 1.6 cm lesion within the gallbladder paralleling the enhancement pattern of the arteries, with the cystic artery feeding it, suggestive of pseudoaneurysm. No active bleeding was demonstrated in the gallbladder, stomach or duodenum.
The gallbladder showed diffuse thickening of the wall with multiple locules of gas in the lumen. Associated pericholecystic inflammatory changes and loss of fat plane between the gallbladder and first part of duodenum were seen, suggestive of cholecystitis with cholecystoduodenal fistula. No dilatation of common bile duct (CBD) or intrahepatic bile ducts was seen.
Ultrasound and colour Doppler revealed thick-walled gallbladder with internal echoes (likely blood). A cystic structure was also seen in the lumen with swirling flow within, confirming the diagnosis of cystic artery pseudoaneurysm. No gallstone was seen.
Discussion
Cystic artery aneurysm and pseudoaneurysm is highly uncommon and is a rare cause of haematemesis - only 22 cases are documented in English literature [1, 2].
The exact aetiopathogenesis is uncertain - acute intra-abdominal inflammation (cholecystitis/pancreatitis), malignancy, biliary trauma or manipulation are postulated to cause vascular adventitial damage and thrombosis of vasa vasorum. This damages the arterial media and intima and ultimately progresses to pseudoaneurysm formation, rupture [2-4] and haemobilia. This process is further accelerated by atherosclerosis, hypertension, bleeding disorders, vasculitis [1-7] and gallstones.
Cystic artery pseudoaneurysms tend to enlarge and erode into the gallbladder or biliary tree [8] to cause symptoms. Clinical presentation is often with biliary colic (70%), obstructive jaundice (60%) or upper GI bleeding (100%) – called Quincke’s triad. Only 32-40% patients present with all three symptoms [5-7, 9].
The initial evaluation for a patient with Quincke’s triad is Ultrasound and colour Doppler. Ultrasound is safe and non-invasive but has limitations in diagnosing subcentimetre lesions. Shadowing from gallstones can also result in missed diagnosis. B-mode ultrasound demonstrates anechoic lesion in the gallbladder lumen and colour Doppler demonstrates vascularity in lesion with the unique 'yin-yang' flow pattern of pseudoaneurysm.
Contrast enhanced CT or 3D-CT Angiogram (CTA) of the abdomen performed on MDCT scanners provides high resolution images. The resolution nearly approaches that of conventional angiography and often points to the diagnosis. If the vascular anatomy is clearly visualized, then CTA can make a definitive diagnosis, with no need for conventional angiography [10].
Selective hepatic arteriography is, however, still considered the gold standard with a sensitivity of 80% and the ability to diagnose aneurysms <1cm. It can often be combined with therapeutic embolization with foam, thrombin or microcoils, either as definitive management or to stabilize the patient haemodynamically before cholecystectomy and aneurysm repair [11].
There is no consensus on management of cystic artery pseudoaneurysm. The choice is between transarterial embolization and open surgery. Embolization has the advantage of reduced morbidity and mortality compared to surgery and is the treatment of choice in presence of haemorrhage, especially in high risk patients. However, if there is associated acute cholecystitis or presence of fistula, cholecystectomy and aneurysm repair is preferred over embolization.
Haemobilia should be included in the differential diagnosis of haematemesis of uncertain aetiology because cystic artery pseudoaneurysm can cause massive haematemesis and result in grave consequences from exsanguination.
The exact aetiopathogenesis is uncertain - acute intra-abdominal inflammation (cholecystitis/pancreatitis), malignancy, biliary trauma or manipulation are postulated to cause vascular adventitial damage and thrombosis of vasa vasorum. This damages the arterial media and intima and ultimately progresses to pseudoaneurysm formation, rupture [2-4] and haemobilia. This process is further accelerated by atherosclerosis, hypertension, bleeding disorders, vasculitis [1-7] and gallstones.
Cystic artery pseudoaneurysms tend to enlarge and erode into the gallbladder or biliary tree [8] to cause symptoms. Clinical presentation is often with biliary colic (70%), obstructive jaundice (60%) or upper GI bleeding (100%) – called Quincke’s triad. Only 32-40% patients present with all three symptoms [5-7, 9].
The initial evaluation for a patient with Quincke’s triad is Ultrasound and colour Doppler. Ultrasound is safe and non-invasive but has limitations in diagnosing subcentimetre lesions. Shadowing from gallstones can also result in missed diagnosis. B-mode ultrasound demonstrates anechoic lesion in the gallbladder lumen and colour Doppler demonstrates vascularity in lesion with the unique 'yin-yang' flow pattern of pseudoaneurysm.
Contrast enhanced CT or 3D-CT Angiogram (CTA) of the abdomen performed on MDCT scanners provides high resolution images. The resolution nearly approaches that of conventional angiography and often points to the diagnosis. If the vascular anatomy is clearly visualized, then CTA can make a definitive diagnosis, with no need for conventional angiography [10].
Selective hepatic arteriography is, however, still considered the gold standard with a sensitivity of 80% and the ability to diagnose aneurysms <1cm. It can often be combined with therapeutic embolization with foam, thrombin or microcoils, either as definitive management or to stabilize the patient haemodynamically before cholecystectomy and aneurysm repair [11].
There is no consensus on management of cystic artery pseudoaneurysm. The choice is between transarterial embolization and open surgery. Embolization has the advantage of reduced morbidity and mortality compared to surgery and is the treatment of choice in presence of haemorrhage, especially in high risk patients. However, if there is associated acute cholecystitis or presence of fistula, cholecystectomy and aneurysm repair is preferred over embolization.
Haemobilia should be included in the differential diagnosis of haematemesis of uncertain aetiology because cystic artery pseudoaneurysm can cause massive haematemesis and result in grave consequences from exsanguination.
Differential Diagnosis List
Cystic artery pseudoaneurysm with cholecystoduodenal fistula secondary to cholecystitis
Hepatic artery pseudoaneurysm
Gallstone (on unenhanced CT images)
Final Diagnosis
Cystic artery pseudoaneurysm with cholecystoduodenal fistula secondary to cholecystitis
References
[1] Chadha M, Ahuja C (2009) Visceral Artery Aneurysms: Diagnosis and Percutaneous Management. Semin Intervent Radiol 26(3): 196–206 (PMID: 21326564)
[2] Komatsu Y, Orita H, Sakurada M, Maekawa H, Hoppo T, Sato K (2011) Report of a case: pseudo aneurysm of the cystic artery with hemobilia treated by arterial embolization. J Med Cases 2(4):178–83
[3] Saluja SS, Ray S, Gulati MS, Pal S, Sahni P, Chattopadhyay TK (2007) Acute cholecystitis with massive upper gastrointestinal bleed: a case report and review of the literature. BMC Gastroenterol 7:12 (PMID: 17386110)
[4] Leung JLY, Kan WK, Cheng SCS (2010) Mycotic cystic artery pseudoaneurysm successfully treated with transcatheter arterial embolization. Hong Kong Med J 16(2):156–7 (PMID: 20354255)
[5] Chong JJR, O’Connell T, Munk PL, Yang N, Harris AC (2012) Case of the month #176:Pseudoaneurysm of the cystic artery. Can Assoc Radiol J 63(2):153–5 (PMID: 22520246)
[6] De Molla Neto OL, Ribeiro MAF, Saad WA (2006) Pseudoaneurysm of cystic artery after laparoscopic cholecystectomy. HPB 8(4):318–319 (PMID: 18333143)
[7] Dewachter L, Dewaele T, Rosseel F, Crevits I, Aerts P, De Man R (2012) Acute cholecystitis with pseudo aneurysm of the cystic artery. JBR-BTR 95(3):136–7 (PMID: 22880508)
[8] Delgadillo X, Berney T, De Perrot M, Didier D, Morel P (1999) Successful treatment of a pseudoaneurysm of the cystic artery with microcoil embolization. J Vasc Interv Radiol 10:789–92 (PMID: 10392949)
[9] Sousa HT, Amaro P, Brito J, Almeida J, Silva MR, Romaozinho JM, Leitao SC (2009) Haemobilia due to pseudoaneurysm of the cystic artery. Gastroenterologie Clinique et Biologique 33: 80-87
[10] Machida H, Ueno E, Shiozawa S, Fujimura M, Tsuchiya A, Kim DH, Ogawa K, Aiba M (2008) Unruptured pseudoaneurysm of the cystic artery with acute calculous cholecystitis incidentally detected by computer tomography. Radiat Med 26(6):384-7 (PMID: 18677616)
[11] Aggarwal A, Goyal S, Choudhary J, Mishra HK, Baberwal MC (2015) Cystic Artery Pseudoaneurysm with Concurrent Cholecysto-Enteric Fistula: A Rare Case Report. Journal of Evolution of Medical and Dental Sciences 4(2): 273-277
Case information
| URL: | https://www.eurorad.org/case/13732 |
| DOI: | 10.1594/EURORAD/CASE.13732 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
CT angiogram - axial image in arterial phase
Round, well-defined, intensely enhancing lesion in gall bladder with enhancement similar to the aorta, suggestive of pseudoaneurysm. Note pericholecystic inflammatory changes and air foci in GB (due to cholecystoduodenal fistula).
Figure 3
Coronal MIP image - arterial phase
Intensely enhancing lesion in gall bladder - the pseudoaneurysm is clearly seen arising from the cystic artery.
Figure 4
Coronal VR image
Cystic artery pseudoaneurysm - Clearly demonstrated on VR adjacent to right hepatic artery.
Figure 5
Coronal MIP image - venous phase
Enhancing lesion in gall bladder parallels arterial enhancement in the delayed phase.
Figure 6
Colour Doppler image of gallbladder
Vascular lesion with colour flow in gallbladder. Gallbladder is thick-walled and shows internal echoes.
Unenhanced CT abdomen
Hyperdensity in gall bladder suggestive of haemobilia.
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
CT angiogram - axial image in arterial phase
Round, well-defined, intensely enhancing lesion in gall bladder with enhancement similar to the aorta, suggestive of pseudoaneurysm. Note pericholecystic inflammatory changes and air foci in GB (due to cholecystoduodenal fistula).
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Coronal MIP image - arterial phase
Intensely enhancing lesion in gall bladder - the pseudoaneurysm is clearly seen arising from the cystic artery.
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Coronal VR image
Cystic artery pseudoaneurysm - Clearly demonstrated on VR adjacent to right hepatic artery.
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Coronal MIP image - venous phase
Enhancing lesion in gall bladder parallels arterial enhancement in the delayed phase.
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Mid Cheshire Hospitals NHS Foundation Trust, Leighton, UK. 2014
Colour Doppler image of gallbladder
Vascular lesion with colour flow in gallbladder. Gallbladder is thick-walled and shows internal echoes.
Mid Cheshire Hospitals NHS foundation Trust, Leighton, UK. 2014
Mid Cheshire Hospitals NHS foundation Trust, Leighton, UK. 2014