LETTER
Hippokratia 2019, 23(2): 95
Zakaria A, Turkalj I, Petrovic DJ
Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
Keywords: Hepatic artery aneurysms, Quincke’s clinical triad, ultrasound, computed tomography
Corresponding author: Zakaria Ahmad, Radiology Department, Clinical Centre of Vojvodina, University of Novi Sad, Novi Sad, Serbia, tel: +38121520577, e-mail: z-ahmad@hotmail.com
Dear Editor,
Hepatic artery aneurysm (HAA) is a rare condition sometimes associated with extreme hemobilia1,2. Hemobilia involves hemorrhage into the biliary tree, which is attributed to an abnormal connection between the biliary tree and liver circulation3.
An 82-year-old woman was admitted to the emergency ward because of right upper abdominal pain and jaundice. Physical examination revealed abdominal guarding while laboratory results indicated leukocytosis (12,000 /mm3) and showed high total bilirubin (9.2 mg/dL), alkaline phosphatase (290 U/L), alanine aminotransferase (115 U/L), aspartate aminotransferase (90 U/L), and gamma-glutamyl transpeptidase (169 U/L) levels, while hemoglobin was 9.1 g/dL, and conjugated bilirubin 7.1 mg/dL. An abdominal ultrasound showed a distended gallbladder filled with echogenic material and a surrounding mass lesion with a positive Doppler signal. Partially visualized common bile duct was dilated, whereas intrahepatic biliary radicles were slightly prominent. There was no evidence of gallstones or gallbladder wall edema. The mass lesion was shown on computed tomography (CT) to be a large, partially thrombosed aneurysm of the common hepatic artery with evidence of intramural hematoma and contrast leakage (Figure 1). Hyperattenuating content was noted within the dilated gallbladder and common bile duct, consistent with hemobilia. The patient eventually underwent surgery. Cholecystectomy and aneurysmectomy were performed, and the portal vein was resected with prosthetic graft interposition. Additionally, external biliary drainage was performed. Due to severe cardiovascular comorbidities, immediate postoperative recovery was complicated, and the patient eventually died.
Figure 1: A large, partially thrombosed common hepatic artery aneurysm is seen on A) volume rendering technique (arrow), B) coronal plain computed tomography (CT) (arrow), and C) coronal postcontrast CT reconstruction (arrow). Hyperattenuating content is seen within the gallbladder lumen (A, B: arrowheads) and common bile duct (B: double arrow). Intravenous contrast leakage is seen (C: triangle).
HAA has a high mortality rate, but it can be managed if detected early. It can be identified according to Quincke’s clinical triad (pale skin, right upper abdominal pain, and gastrointestinal hemorrhage)2.
CT or angiography scans can easily locate HAA. The regional vascular anatomy and HAA location are factors to consider before treatment planning. After defining the exact location and anatomic relations, treatment decisions include the stenting of the vessel and open surgical repair with reconstruction.
Conflict of interest
None reported.
References
1. Burns L, Slakey DP. Laparoscopic management of massive hemobilia from an intrahepatic aneurysm. JSLS. 2009; 13: 60-63.
2. Harlaftis NN, Akin JT. Hemobilia from ruptured hepatic artery aneurysm. Report of a case and review of the literature. Am J Surg. 1977; 133: 229-232.
3. CreŢu OM, Dan RG, Blidişel IAC, Sima LV, Munteanu M, Păun I. Hemobilia through aneurysm of the right hepatic artery, 22 months after laparoscopic cholecystectomy: case presentation. Rom J Morphol Embryol. 2017; 58: 197-199.