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Those pesky gallstones, again…a cause of PR bleeding.

Those pesky gallstones, again…a cause of PR bleeding. Dr Liam Ingram Dr Mohammed Bajalan Dr Nigel Hacking. Clinical presentation. 76 yr old male Epigastric pain and PR bleeding PMHx – hypertension, MI, limited right colon (caecum) for adenoma, chronic calculous cholecystitis

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Those pesky gallstones, again…a cause of PR bleeding.

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  1. Those pesky gallstones, again…a cause of PR bleeding. Dr Liam Ingram Dr Mohammed Bajalan Dr Nigel Hacking

  2. Clinical presentation • 76 yr old male • Epigastric pain and PR bleeding • PMHx – hypertension, MI, limited right colon (caecum) for adenoma, chronic calculous cholecystitis • Examination – Mild upper abdominal tenderness • Patient transfused

  3. Initial investigations • Bloods - Hb 87g/l - bil 22, ALT 109, ALP743 • OGD – Normal • Colonoscopy – Blood clots, no source • CT - ?!

  4. CT Cholecystoenteric fistulae 23mm Cystic artery pseudoaneurysm Gallstones Reduction in number of gallstones since previous CT

  5. Embolisation attempted Unfortunately, the cystic artery could not be selectively engaged. Small calibre cystic artery Pseudoaneurysm

  6. US guided percutaneous transhepatic thrombin injection • Two separate injections were required to occlude the pseudoaneurysm • Elective cholecystectomy and primary fistulae repair (right hemi-colectomy)

  7. Literature • No other reported case found with concurrent pseudoaneurysm and colonic fistula • Rare, cystic artery pseudoaneurysm from cholecystitis1,2 • Usually decompresses into GB and biliary tree • Fistulae rare complication of acute cholecystitis (0.15-4.8%)3,4 • Pseudoaneurym risk worse if vascular risk factors5

  8. Learning points • PR bleeding can originate from foregut • Gas in gallbladder can suggest enteric fistulae • Cholecystitis can cause pseudoaneurysm formation and associated bleeding • Endovascular and percutaneous treatment minimally invasive and effective (80-100%) 2,6

  9. References 1. Akatsu, T., Tanabe, M., Shimizu,T. et al. Pseudoaneurysm of the cystic artery secondary to cholecystitis: report of a case. Surgery Today 2007:37 (5):412-7. 2. Nana, G.R., Gibson, M., Speirs, A. et al. Upper gastrointestinal bleeding: A rare complication of acute cholecystitis. Int J Surg Case Rep. 2013;4(9):761-4. 3. Glaysher, M.A., Cruttended-Wood, D., Szentpali, K. A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula. Int J Sur Case Rep. 2014;5(1):1-4. 4. Chowbey, P.K., Bandyopahyay, S.K., Sharma, A. et al. Laparoscopic management of cholecystoenteric fistulas. Ja Laparoendosc Adv Surg Tech A 2006;16(5):467-72. 5. Majid, T.A., Ahmad, R.R., Jawad, R.R. et al. Cystic artery pseudoaneurysm: a rare but serious complication after cholecystecomy. Report of three cases. Postgrad Med J 2007:6(2):164-8. 6. Deai, A., Saunders, M.P., Anderson, H.J. et al. Successful transcatheter arterial embolisation of cystic artery pseudoaneurysm secondary to calculus cholecystitis: a case report. Journal of Radiology Case Reports. 2010;4(2)18-22. Special Thanks – Dr R Allison, Dr T Bryant

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