A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula
An 86-year-old male presented to the Emergency Department with a two-day history of colicky right upper quadrant (RUQ) pain associated with bilious vomiting. Relevant background included hypertension, diabetes mellitus and hypercholesterolaemia. On examination, the patient was icteric with an associated pyrexia of 38 °C, hypotension and tachycardia. Abdominal examination revealed mild tenderness in the RUQ.\nLaboratory investigation revealed raised inflammatory markers with a white blood cell count of 24.0 × 109 L−1 and C-reactive protein of 95 mg/L (Normal range: <7.5 mg/L). Liver function tests (LFTs) were also deranged with an alkaline phosphatase of 450 μ/L (46–111 μ/L), Alanine Transaminase of 142 μ/L (<45 μ/L) and Bilirubin of 60 μmol/L (<20 μmol/L). An ultrasound examination revealed a 5.7 cm calculus within the gallbladder surrounded by heterogeneous material; a diagnosis of cholangitis was made. The patient received fluid resuscitation with intravenous crystalloid and was commenced on broad-spectrum antibiotics.\nSubsequently, the patient passed a significant volume of malaena and fresh blood per rectum (PR), associated with cardiovascular instability. Emergency oesophagogastroduodenoscopy (OGD) revealed fresh blood in the second part of the duodenum and a tubular clot adherent to the medial wall (). This was assumed to be originating from a duodenal ulcer and apparent haemostasis was achieved with injection of 15 ml of 1:10,000 adrenaline. However, the patient continued to pass malaena and PR blood following the procedure. As such, a contrast-enhanced computed tomography (CT) scan was performed, demonstrating: (1) small bowel obstruction secondary to a gallstone impacted in the distal ileum (a) (2) a thick-walled and inflamed gallbladder with evidence of recent intra-cholecystic bleeding (b), and (3) a 12 mm pseudoaneurysm emanating from the cystic artery (c and d). In retrospect, the blood clot seen at OGD was likely to be haemobilia originating from the ampulla of Vater.\nThe patient underwent emergency laparoscopy and the gallbladder was found to be necrotic and surrounded with dense adhesions. Division of these exposed a cholecysto-jejunal fistula containing clotted blood that was extending into the gallbladder. Evacuation of this clot revealed a 1 cm × 2 cm pseudoaneurysm originating from the cystic artery, which began to bleed during dissection and the procedure was subsequently converted to an open laparotomy via a Kocher incision. A subtotal cholecystectomy was performed with oversewing of Hartmanns pouch and the aneurysm was successfully resected from the gallbladder fossa. The diseased jejunal loop was mobilised and the defect from the fistula was oversewn. Despite detailed examination of the small bowel, the gallstone located on CT could not be identified within the terminal ileum. The laparotomy wound was therefore closed under the assumption that the stone had passed spontaneously. The patient was discharged following a fifteen-day inpatient stay and remained well at six-week outpatient follow-up.