Right hepatic artery pseudoaneurysm with hemobilia and common bile duct fistula following laparoscopic cholecystectomy: a case report

¹National Center of Gastrointestinal and Liver Diseases, Ibn Sina Center Specialized Hospital, Khartoum, Sudan

^&Corresponding author
Hossam Elamin Khalifa, National Center of Gastrointestinal and Liver Diseases, Ibn Sina Center Specialized Hospital, Khartoum, Sudan

Introduction    

Laparoscopic cholecystectomy has been the gold-standard treatment for gallstone disease for three decades, but it still carries a real risk of biliary and vascular injury. Vascular complications are reported less often than biliary ones [1], yet they occur in much the same way - laceration, transection, or occlusion of a vessel during dissection of Calot's triangle, most often involving the cystic artery, the right hepatic artery, and only rarely the portal vein [2]. Hepatic artery pseudoaneurysm is an uncommon example of this, described mainly through isolated case reports [1], and it can present either early or late after surgery, which makes it a genuine diagnostic and therapeutic challenge [3]. The proposed mechanism is injury to the arterial wall from dissection close to the right hepatic artery, from a misplaced clip, from adjacent inflammation, or from thermal spread during diathermy. We report a right hepatic artery pseudoaneurysm presenting with hemobilia 26 days after an apparently uneventful laparoscopic cholecystectomy - a case that also illustrates how a small, seemingly reassuring collection on early postoperative ultrasound can be the first sign of a much larger problem still to come.

Patient and observation     

Patient information: the patient was a 38-year-old woman, married for 15 years and the mother of four children, with recurrent right hypochondrial pain and fatty food dyspepsia. Abdominal ultrasonography led to a diagnosis of chronic calculous cholecystitis, for which she underwent an uneventful laparoscopic cholecystectomy and was discharged home in good condition. She had no other relevant past medical, family, or psychosocial history. After discharge from the hospital, the patient did not feel well; she had a low-grade fever and vomiting, and on postoperative day 8 she was readmitted with jaundice, right hypochondrial pain, and high-grade fever. Abdominal ultrasound showed only a small collection in the gallbladder bed and Morison's pouch. She was managed conservatively with intravenous fluids, antibiotics, and analgesia, and discharged after improvement. On postoperative day 26, she presented critically unwell, with jaundice, severe abdominal pain, dark urine, high fever, hematemesis, and melena. Her treating surgeon referred her from the primary unit to the bleeding center, where she was admitted to the gastroenterology unit.

Clinical findings: on her second readmission, 26 days after surgery, she looked unwell: pale and jaundiced, with a pulse rate of 110/min, respiratory rate of 25/min, and blood pressure of 85/55 mmHg. Her chest was clear, and her cardiovascular examination was otherwise normal. The abdomen was non-distended with tenderness in the upper abdomen but no peritonism. Anal tone was normal on rectal examination, with no mass, but dark, melenic blood was found on the glove.

Timeline: the sequence of events from the index operation to final follow-up is summarized in Table 1.

Diagnostic assessment

Laboratory findings: blood tests on the second admission showed hemoglobin 7.4 g/dL, hematocrit 22%, total white cell count 19 x10³/µL, and platelets 242 x10³/µL. Total/direct bilirubin was 19/15 mg/dL, alkaline phosphatase (ALP) 355 U/L, International Normalized Ratio (INR) 1.4, creatinine 0.8 mg/dL, and arterial pH 7.33. These are summarized in Table 2.

Endoscopy and imaging: upper GI endoscopy showed only a small hiatus hernia, with a normal esophagus, stomach, and duodenum - no bleeding source was identified there, which pointed away from a peptic cause for her hematemesis and melena. Abdominal ultrasound showed intrahepatic and common hepatic duct dilatation extending down to the porta hepatis, where a 5.7 x 4.3 cm collection was compressing the common hepatic duct; the liver was otherwise normal, and there was no free intraperitoneal fluid. MRCP confirmed marked intrahepatic and common hepatic duct dilatation with an abrupt cut-off at the level of the common hepatic duct (Figure 1).

Diagnostic reasoning: given the combination of biliary obstruction, hemobilia, and a porta hepatis collection appearing weeks after cholecystectomy, a right hepatic artery pseudoaneurysm was strongly suspected on clinical grounds. CT angiography was requested and confirmed the diagnosis (Figure 2), establishing this as a post-cholecystectomy right hepatic artery pseudoaneurysm with associated hemobilia.

Therapeutic intervention: the initial plan was endovascular embolization of the pseudoaneurysm. Before this could be carried out, however, the patient became hemodynamically unstable, and the decision was made to proceed instead to emergency laparotomy. At operation, a large pseudoaneurysm was found in the extrahepatic portion of the right hepatic artery. A Pringle maneuver was performed to control inflow, and the aneurysm was resected; the right hepatic artery was doubly ligated both proximally and distally. The aneurysm was found to have eroded into the distal common bile duct, creating a fistula. A double pigtail stent was passed proximally up to the level of the intrahepatic biliary tree and distally to the level of the duodenum, and the fistula was closed with interrupted 4/0 PDS sutures. The rest of the operative field - the left hepatic artery, portal vein, and duodenum - was normal. A drain was left in the hepatic hilum and the abdomen was closed in layers.

Follow-up and outcomes: the postoperative course was uneventful. She stayed in hospital for 4 days; her investigations showed hemoglobin 11 g/dL, bilirubin 2 mg/dL, and ALP 170 U/L. Drain output was less than 50 mL/day, and the drain was removed on the third postoperative day; she was discharged on the fourth postoperative day. The biliary stent was removed after 8 weeks through ERCP without complications. She was followed for one year postoperatively, every 3 months, with abdominal ultrasound, hepatic Doppler, liver function tests, and GGT, all of which remained normal.

Patient perspective: the patient expressed that she was very satisfied with the care and treatment she received throughout her illness. She was grateful for the efforts of our medical team and felt happy and proud of the team's dedication and support during her treatment and recovery. Following her recovery, she expressed a positive outlook and appreciation for the care she received. After reviewing and approving this statement, she gave her permission for her case to be published.

Informed consent: written informed consent was obtained from the patient for publication of this case report and the accompanying clinical images.

Discussion     

Laparoscopic cholecystectomy remains the gold standard for symptomatic gallstone disease, but it is not free of risk: biliary injuries occur in roughly 0.2-1% of procedures, about ten times more often than after open surgery, while vascular injuries occur in around 0.25-0.5% [3,4]. Most vascular injuries are bleeding from the cystic artery stump, the right hepatic artery, or, less often, the portal vein [4]. A pseudoaneurysm of the hepatic artery is a rare complication of that injury, arising in either the early or late postoperative period, and it is what makes hemobilia - bleeding into the biliary tree - possible [1]. Other, less common causes of hemobilia include abdominal trauma, liver surgery, and percutaneous liver interventions such as biopsy or biliary stenting [5].

Hemobilia itself has been recognized since the seventeenth century [6], but it remains rare enough, and its presentation varies enough, that the diagnosis is often delayed. The classic description - right upper quadrant pain, jaundice, and upper gastrointestinal bleeding, known as Quincke's triad - is actually present in only about a quarter to a third of patients [7], which was borne out in our patient, who also had fever and hemodynamic compromise on top of the triad. Most cases of hemobilia are iatrogenic, arising from invasive hepatobiliary or pancreatic procedures, with trauma and malignancy accounting for most of the rest [6]. Because the classic triad is unreliable, the diagnosis depends heavily on clinical suspicion - particularly in anyone who has recently had biliary or hepatic instrumentation [6].

Laboratory findings typically mirror what we saw here: rising bilirubin and ALP from biliary obstruction by clots or by the pseudoaneurysm itself, and falling hemoglobin and hematocrit from ongoing blood loss. Ultrasound may show a pulsatile, hypoechoic mass with flow on Doppler, but CT angiography remains the most reliable way to confirm the diagnosis [8], as it did in this case. Exactly why these pseudoaneurysms form after laparoscopic cholecystectomy is still debated; proposed mechanisms include arterial wall erosion around a surgical clip, direct injury to the vessel wall during dissection, thermal injury from diathermy used near the hepatic pedicle, and inflammation eroding the cystic artery stump [1,9].

Strengths and limitations

This case adds a well-documented example of a rare complication with a clear timeline from surgery to definitive repair, including endoscopic, radiological, and intraoperative confirmation. Its main limitation is the absence of interventional radiology; embolization, the first-line treatment, could not ultimately be performed because of hemodynamic instability.

Conclusion     

A right hepatic artery pseudoaneurysm can present weeks after an uneventful laparoscopic cholecystectomy, sometimes preceded by a deceptively minor finding - such as a small fluid collection on an early postoperative ultrasound - that resolves with conservative treatment before the real problem declares itself. When jaundice, gastrointestinal bleeding, or sepsis develop in this setting, hemobilia from a hepatic artery pseudoaneurysm should be considered even without the full classic triad, and CT angiography should be obtained early. Endovascular embolization is the first-line treatment, but surgeons managing these patients need to be ready to move to open repair without delay if the patient becomes hemodynamically unstable, since that readiness can be lifesaving.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conceptualization: Abderrhaim Ali Dabora, Hossam Elamin Khalifa. Methodology and data curation: Abdelmonim Eltyeb Abdo, Hossam Elamin Khalifa, Musadag Ali Dabora. Investigation: Montasir Abdelsakhi, Maha Ali Omer. Writing - original draft: Hossam Elamin Khalifa. All authors have read and approved the final version of this manuscript.

Tables and figures     

Table 1: timeline of clinical events.

Table 2: laboratory findings on the second (index) admission

Figure 1: magnetic resonance cholangiopancreatography (MRCP) showing marked intrahepatic and common hepatic duct dilatation with abrupt cut-off at the level of the common hepatic duct, secondary to extrinsic compression by the porta hepatis collection

Figure 2: computed tomography angiography confirming a right hepatic artery pseudoaneurysm

References