247Saudi Journal of Medicine & Medical Sciences | Vol. 3 | Issue 3 | September 2015 | 247-247

Post Laparoscopic Cholecystectomy Hematemesis

A 27-yar-old woman underwent laparoscopic cholecystectomy. One week later, she presented with abdominal pain and tachycardia. The emergency laparotomy showed bleeding in the surgical bed. Hemostasis was achieved and drain inserted. The drain output was bilious in the first postoperative day. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and revealed a bile duct leak and

image Quiz

stent was inserted. Six weeks later, the patient presented with massive hematemesis. Selected angiogram shown in Figure 1 and computed tomography (CT) scan is depicted in Figure 2. After the initial management, the patient was discharged home, but she came back 3 weeks later with another episode of hematemesis. A second selective angioembolization [Figure 3] failed to resolve her condition.

QUESTIONSWhat is the cause of her presentation?What is the cause of the complications?What is the possible diagnosis?

ANSWERSee answers in page 249.

Figure 1: Selective angiogram showing biliary stent and the cause of the patient hematemesis and intervention.

Figure 2: Computed tomography scan with contrast showing the surgical clips and extravasation of contrast.

Figure 3: The second selective angiogram showing persistent finding and repeated intervention done.

Figure 4: intraoperative photo showing the right hepatic artery aneurysm being opened and coiled removed than ligation of the right hepatic artery.

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DOI:10.4103/1658-631X.162043

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Saudi Journal of Medicine & Medical Sciences | Vol. 3 | Issue 3 | September 2015 | 248-248248

September 201506 – 09 2015 International Lung Cancer Conference Venue: Denver, Colorado, USA24 – 26 3rd International Conference on Vaccines and Vaccination Venue: Valencia, Spain24 – 26 3rd International Conference on Clinical Microbiology & Microbial Genomics Venue: Valencia, Spain26 – 30 2015 Meeting of the European Respiratory Society Venue: Amsterdam, The Netherlands

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249Saudi Journal of Medicine & Medical Sciences | Vol. 3 | Issue 3 | September 2015 | 249-249

ANSWER

The cause of hematemesis is hemobilia caused by a leaking right hepatic artery aneurysm through a side injury of the common bile duct (CBD). The biliary stent was partially preventing continuous hemobilia occurring periodically due to vigorous activity that increased the pressure in the aneurysm. Second angioembolization failed again, and the patient underwent exploration laparotomy which showed the mentioned findings. The patient underwent right hepatic artery ligation and primary repair of the CBD injury (Figure 4). After a second-look laparotomy, the patient had a smooth recovery. However, she had pulmonary embolism before the laparotomy, and inferior vena cava filter inserted. Postoperatively, she was put on anticoagulant and discharged home 2 weeks later on warfarin. At 3-month follow-up, the patient had remarkable recovery.

DISCUSSION

Upper gastrointestinal hemorrhage from hepatic artery pseudoaneurysm is a rarely reported complication of laparoscopic cholecystectomy occurring with a reported frequency of 0.06% of all cases with a mortality of 2.3%.[1] This complication is unique to the laparoscopic approach and is essentially unheard of in the era of open cholecystectomy. Bleeding can be early or delayed, occurring weeks or months after surgery.[2,3] Endoscopy may not establish the diagnosis as bleeding is often intermittent. Angiography should be the diagnostic procedure of choice as it offers immediate intervention. There are few case reports of hemobilia due to hepatic pseudoaneurysm post laparoscopic cholecystectomy[3-11] and one small series describing selective embolization.[2]

Hanan M. AlghamdiHepatobiliary and Transplant Surgeon, Assistant Professor

of Surgery, Department of Surgery, College of Medicine, University of Dammmam, King Fahd Hospital of the University,

Dammam, Kingdom of Saudi Arabia

Answers of Quiz

Correspondence: Dr. Hanan M. Alghamdi, University of Dammam,

King Fahd Hospital of the University, P. O. Box 40020, Al-Khobar 31952,

Kingdom of Saudi Arabia. E-mail: hmalghamdi@uod.edu.sa

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