Post‐cholecystectomy haemobilia: a rare complication

A 37-year-old Maori woman with a background history of ventral septal defect repair and aortic valve replacement (bioprosthetic) presented to the emergency department with biliary colic. Deranged liver function tests (LFTs) necessitated a magnetic resonance cholangiopancreatography scan (MRCP) which failed to define choledocholithiasis and she underwent an uneventful laparoscopic cholecystectomy with normal operative cholangiogram. She was discharged from hospital shortly thereafter. The patient represented on the 11th post-operative day with abdominal pain, deranged LFTs and an elevated serum lipase. A computed tomography (CT) scan of the abdomen showed intra- and extrahepatic duct dilatation without an obvious cause. Whilst originally considered for endoscopic retrograde cholangiopancreatography (ERCP), the patient's pain and biochemistry resolved without intervention and she was discharged. The patient represented on the 31st post-operative day again with right upper quadrant abdominal pain, mildly deranged LFTs, elevated serum lipase and for the first time, a single episode of haematemesis. An inpatient upper gastrointestinal (UGI) endoscopy and endoscopic ultrasound were planned. Prior to this occurring, evidence of fulminant UGI haemorrhage ensued with melaena and one further large episode of haematemesis. An urgent CT abdomen angiogram was performed, and this demonstrated an 11 mm pseudoaneurysm in segment VII of the liver with evidence of haemorrhage (Fig. 1). UGI endoscopy was then promptly performed, and this excluded any luminal pathology, with the only finding being that of blood products extruding from the ampulla of Vater (Fig. 2). On the basis of an actively bleeding hepatic pseudoaneurysm, the patient was transferred for a hepatic angiogram which confirmed an actively bleeding segment VII pseudoaneurysm that was successfully coil-embolised (Fig. 3). The patient made an uncomplicated recovery thereafter including resolution of deranged LFTs. Cholecystectomy is a common general surgical operation with a well-defined complication profile. Serious vascular complications occur in up to 1.97% of cases, with trocar insertion the most common cause.1 Intra-hepatic hepatic artery pseudoaneurysms (HAP) are not a common complication but are likely under-reported2 with historical morbidity reported in up to 35% of cases,3 however more recent data are lacking. The right hepatic artery and branches are the most reported vessel involved in cholecystectomy-associated pseudoaneurysm due to its proximity to the gallbladder fossa.2 In the absence of any other potential mechanism, it can only be assumed that the cholecystectomy resulted in injury to the vasculature and predisposed to development of what ultimately became a complicated pseudoaneurysm. Beyond this, the manner of presentation of the complication was also relatively unique, with decompression into the biliary tree, manifesting with what appeared to be UGI haemorrhage. Quincke's triad of abdominal pain, jaundice and UGI bleeding describes the clinical manifestation of haemobilia and was observed acutely in this patient, aiding in the diagnosis.4 While it is established that the most common aetiology of symptomatic HAP is iatrogenic, the exact mechanism is often difficult to define. Excessive manipulation/traction, thermal injury during dissection of hepato-cystic triangle structures/cystic plate or irritation from spilled bile may contribute. This patient's post-operative pancreatitis, presumed to be as a result of biliary sludge, whilst a consideration is unlikely to have contributed to the development of the HAP in this case. Angiography coil embolisation is the management of choice in complicated hepatic pseudoaneurysms and was successfully employed in the present case. Whilst uncommon, recognition of the clinical sequela of haemobilia in post-cholecystectomy patients is important in reducing morbidity. In conclusion, surgeons should be aware of the potential for iatrogenic damage to all extra- and intra-hepatic bilio-vascular structures. This includes the potential for development of a pseudoaneurysm that can become complicated and present in an unorthodox fashion. Open access publishing facilitated by Griffith University, as part of the Wiley - Griffith University agreement via the Council of Australian University Librarians. Thomas G. Mackay: Writing – original draft; writing – review and editing. Damien J. Gardiner: Writing – review and editing. Justin S. Gundara: Supervision; writing – original draft; writing – review and editing.