PICTURES IN DIGESTIVE PATHOLOGY

1130-0108/2017/109/8/587-588Revista española de enfeRmedades digestivas© Copyright 2017. sepd y © ARÁN EDICIONES, S.L.

Rev esp enfeRm dig2017, Vol. 109, N.º 8, pp. 587-588

Hemobilia due to a cystic artery pseudoaneurysm on ultrasoundVictoria 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

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 gall-bladder 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 differ-ent 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 iatro-genic 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

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 intra-venous contrast, indicating its vascular origin within the gallbladder (arrow). It communicates with the cystic artery and represents the arte-rial pseudoaneurysm.

588 V. DE-LARA-BENDAHÁN ET AL. Rev esp enfeRm Dig

Rev esp enfeRm Dig 2017;109(8):587-588

two colors due to the turbulent flow inside the pseudoan-eurysm. 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.

REFERENCES

1. Asad Ali, Sofronis Loizides, Richard Newton, et al. Laparoscopic manage-ment of a cystic artery pseudoaneurysm in a patient with calculus cholecys-titis. 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.