St. Luke's University Hospital Easton, PA, United States
Nishit Patel, MD1, Sagar V. Mehta, MD2, Berhanu Geme, MD2, Jamie Thomas, DO2, Hany Eskarous, MD2 1St. Luke's University Hospital, Easton, PA; 2St. Luke's University Hospital, Bethlehem, PA
Introduction: Visceral artery aneurysms are rare, but the hepatic arterial territory is the second most involved site. Most are diagnosed incidentally, however a rupture may lead to a life-threatening hemorrhage that can present as a recurrent upper gastrointestinal bleeding which can be difficult to control endoscopically. We present a 71-year-old female with a history of cholangiocarcinoma who developed recurrent GI bleeding from a suspected duodenal ulcer in the setting of a hepatic artery pseudo-aneurysm necessitating a multidisciplinary team-based approach for successful hemostasis.
Case Description/Methods: We present a 71 year old female with history of intrahepatic cholangiocarcinoma status post segmental hepatic resection, radiation therapy and indwelling palliative transhepatic billiary drain who was seen for hematochezia and anemia requiring transfusion. She underwent EGD which showed a seemingly Forrest class 1A duodenal ulcer, distal CDB with 1 cm perforation and indwelling metal stent [image 1]. The bleeding was not controlled by dual endoscopic treatment including clipping and epinephrine injection. Visceral angiogram by interventional radiology revealed no evidence of active bleeding or extravasation from GDA however it did reveal a pseudoaneursym of the proper hepatic artery distal to GDA [image 2]. This was presumably the cause of bleeding in form of hemobilia. It was treated with a covered stent. At this time, decision to embolize the GDA was made to achieve seal and prevent a possibility of endoleak in future as stent crossed the origin of GDA. On subsequent monitoring she continued to have drop in hemoglobin. Repeat EGD at the time showed similar ulcer and CBD defect with unsuccessful endoscopic hemostasis. A repeat angiography was performed which revealed a new pseudoaneurysm of the proper hepatic artery distal to previously placed stent. It was treated with a covered bond stent across the distal portion of previously placed stent. She was not noted to have any further bleeding subsequently and was eventually discharged.
Discussion: Hemobilia is usually not controlled by endoscopic treatment and requires urgent IR intervention which can prevent tragic outcomes. Our case is interesting as the bleeding was initially suspected to be from duodenal ulcer, but it only turned out to be a red herring. The actual source of bleeding was hemobilia due to pseudoaneurysm in setting of possible radiation induced vasculopathy and prior endoscopic manipulations.
Figure: Image 1: Seemingly Forrest 1A Duodenal Ulcer. Image 2: Pseudo-Aneurysm Distal To The GDA. No Extravasation Seen At The Site Of Endo-Clips.
Nishit Patel indicated no relevant financial relationships.
Sagar Mehta indicated no relevant financial relationships.
Berhanu Geme indicated no relevant financial relationships.
Jamie Thomas indicated no relevant financial relationships.
Hany Eskarous indicated no relevant financial relationships.
Nishit Patel, MD1, Sagar V. Mehta, MD2, Berhanu Geme, MD2, Jamie Thomas, DO2, Hany Eskarous, MD2. P2591 - Hemobilia Due to a Hepatic Artery Pseudo-Aneurysm, Mimicking an Actively Bleeding Duodenal Ulcer, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.