Idiopathic cystic artery aneurysm complicated with hemobilia
A 35-year-old male patient presented with severe hematemesis and upper right quadrant abdominal pain. He had a history of recurrent vague abdominal pain and melena for the last 3 months and was treated symptomatically at a local hospital. He did not undergo any surgeries or diagnostic\nprocedures. He had a known history of hypertension, a family history of hypertension, and was under amlodipine. He had no history of smoking, alcohol consumption, or drug abuse. On admission, the patient was afebrile and non-icteric. His blood pressure was 110/60 mmHg, respiratory rate was 20/min, and pulse rate was 100 bpm. Physical examination revealed a well-nourished and oriented young man. The upper right quadrant appeared full and tender to palpation but without rebound tenderness. Rectal examination showed fresh blood. The remainder of the physical examination was normal. Laboratory investigation revealed an elevated white blood cell count of 20×103/μL, hemoglobin of 8.5 g/dL and platelet count of 22 7×103/μL. Blood chemistry showed SGOT:149 U/L (0-37), SGPT:203U/L (0-40), Bilirubin total/conjugated:1.27/0.52 (units?), GGT:872 U/L, total protein/albumin:5.70/3.10 g/dL. Upper GI endoscopy revealed blood was likely to be coming out from pylorus. CT scan revealed markedly distended gallbladder lumen filled with high Hounsfield Unit (H.U.) (60-70) content suggestive of blood along with a 20 mm x 16 mm in size, well-defined, intensely enhanced lesion arising from the wall of the body of the gallbladder and very likely representing vascular pathology []. MR angiography revealed a 21×17 mm sized aneurysm arising from the terminal end of the cystic artery with a secondary bleeding within gallbladder lumen [,].\nThe patient was referred for surgery due to radiological findings of associated cholecystitis. He underwent open cholecystectomy and aneurysm repair. Intraoperatively the gallbladder was hugely distended and there was dense adhesion surrounding the gallbladder and the Callot’s triangle anatomy was distorted. Gallbladder was opened on fundus and blood clots were drained []. There was active spurt from the body of the gallbladder following removal of clot-like material which was controlled using 4’0 synthetic, monofilament, nonabsorbable polypropylene suture. Cholecystectomy was then performed following dissection of Callot’s triangle and individually ligating the cystic artery and duct. The condition of the patient remained clinically stable and subsequent follow-up showed normal hemoglobin levels. Histopathological examination revealed chronic cholecystitits. The patient was discharged after 7 days with a plan for outpatient follow-up.