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Year 2017 / Volume 109 / Number 8

Digestive Diseases ImageHemobilia due to a cystic artery pseudoaneurysm on ultrasound587-588Victoria de Lara Bendahán, Encarna García DomÍnguez, Marta Rivas Rivas, Jesús García SerranoThe present paper describes a case of hemobilia in a woman with a cystic artery pseudoaneurysm.The pseudoaneurysm could be seen with ultrasound, Doppler sonography and CT angiography. In ourcase, Doppler sonography was the most useful technique for diagnosis, revealing the turbulentforward and backwards flow within the gallbladder, representing the focally dilated artery. This waslater confirmed by CT angiography. A recent bleeding site was found on the cholecystectomyspecimen.

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IPD 4936 inglés

Hemobilia due to a cystic artery pseudoaneurysm on ultrasound

Victoria De-Lara-Bendahán1, Encarna García-Domínguez2, Marta Rivas-Rivas2 and Jesús

García-Serrano1

Clinical Management Unit of 1Radiodiagnosis and 2Digestive Diseases. Hospital

Universitario de Puerto Real. Cádiz, Spain

Correspondence: Victoria de Lara Bendahán

e-mail: victoria-de-lara@hotmail.com

CASE REPORT

An 85-year-old woman with a history of gallbladder stones presented with epigastric

pain and vomiting. Blood chemistry showed: GGT 350, AP 215, bilirubin 3.4 (direct 2.6)

and CRP 2.11. Ultrasound revealed a thickened gallbladder with a stone, echogenic bile

and a 3-cm intravesical collection around the calculus (Fig. 1). Doppler examination

showed bidirectional vascular flow expressed as two different colors within the

intravesical collection (Fig. 2).

Later she presented with melena, which prompted an endoscopic retrograde

cholangiography procedure that resulted in bleeding and clot removal. An angio-CT

scan was performed due to the suspicion of hemobilia due to a pseudoaneurysm

complicating calculus cholecystitis. The scan showed a dilated cystic artery with a

pseudoaneurysm (Fig. 3). The laparoscopic cholecystectomy specimen had a recent

bleeding site.

DISCUSSION

Cystic artery pseudoaneurysm is a rare, usually iatrogenic cause of hemobilia (1),

although cases secondary to cholecystitis have been reported (2). Arterial wall erosion

from inflammation may cause its development (2).

Ultrasound may identify the focally dilated artery as a collection within the gallbladder

(3). Doppler ultrasound revealed bidirectional vascular flow which is a mix of two

colors due to the turbulent flow inside the pseudoaneurysm. This is known as the “yin-

yang sign” due to its similarity with the Asian symbol (3). CT angiography or

arteriography demonstrated the focally dilated artery (1). However, doppler

ultrasound was the most useful study to confirm the suspicion in a rapid, effective,

non-invasive manner in our case.

REFERENCE

1. Asad Ali, Sofronis Loizides, Richard Newton, et al. Laparoscopic management of

a cystic artery pseudoaneurysm in a patient with calculus cholecystitis. Int J Surg Case

Rep 2015;14:182-5. DOI: 10.1016/j.ijscr.2015.08.007

2. De Quinta Frutos R, Moles Morenilla L, Docobo Durantes F, et al. Hemobilia

secondary to chronic cholecystitis. Rev Esp Enferm Dig 2004;96:221-5. DOI:

10.4321/S1130-01082004000300009

3. Badano F. Signo del Yin-Yang. Rev Arg Radiol 2010;74:403-5.

Fig. 1. Gallbladder with a thickened wall from inflammatory changes, echogenic bile

contents that looked like blood (hemobilia) or sludge and a hyperechogenic stone with

a posterior acoustic shadow (thin arrow). An anechoic oval image corresponding to a

3-cm collection around the calculus (thick arrow) was also seen which represented the

cystic artery pseudoaneurysm, a condition unsuspected with ultrasound alone.

Fig. 2. Doppler ultrasound revealing vascular flow within the lesion surrounding the

stone. The flow was bidirectional, both anterograde and retrograde, as represented by

the two colors (thick arrow). This hemodynamic disturbance shape is typical of vascular

lesions such as pseudoaneurysms, and is known as the “yin-yang” sign due to the

similarity with the well-known Asian symbol.

Fig. 3. Angio-CT scan showing a 3-cm sac-like structure filled with intravenous contrast,

indicating its vascular origin within the gallbladder (arrow). It communicates with the

cystic artery and represents the arterial pseudoaneurysm.