CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 5 (2014) 142–144
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy夽 Ahmet Rencuzogullari a,∗ , Alexis K. Okoh b , Tolga A. Akcam a , Emir Charles Roach c , Kubilay Dalci a , Abdullah Ulku a a
Cukurova University School of Medicine, Department of Surgery, Turkey Ankara University School of Medicine, Department of Surgery, Turkey c Cleveland Clinic, Department of Pathobiology, United States b
a r t i c l e
i n f o
Article history: Received 13 November 2013 Received in revised form 3 January 2014 Accepted 9 January 2014 Available online 17 January 2014 Keywords: Laparoscopic cholecystectomy Hemobilia Pseudoaneurysm Right hepatic artery
a b s t r a c t INTRODUCTION: Laparoscopic cholecystectomy has many complications which may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the biliary system. PRESENTATION OF CASE: A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient, Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiography were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed. The patient recovered completely. DISCUSSION: Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure. CONCLUSION: In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients. © 2014 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved.
1. Introduction Laparoscopic cholecystectomy has similar morbidity and mortality in experienced hands with open cholecystectomy. However, many complications may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field. Vascular injuries are a common complication of laparoscopic cholecystectomy. In this case report we are presenting a rare entity: pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the
夽 This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. ∗ Corresponding author at: Cukurova University School of Medicine, Balcali Hospital, Department of General Surgery, Saricam, Adana 01330, Turkey. Tel.: +90 5321798280; fax: +90 3223386432. E-mail addresses: [email protected], [email protected] (A. Rencuzogullari).
biliary system. Our diagnostic approach is described and treatment method alongside current treatment modalities is discussed. 2. Case report A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. The procedure was uneventful with no complication during surgery reported in his records. On examination, he was pale; blood pressure was 90/60 mmHg and pulse rate was 110 bpm. Mild epigastric tenderness and right upper quadrant pain upon palpation were noted. Laboratory investigations revealed the following: hemoglobin 8.5 g/dl, white cell count 8.5 × 109 /l, platelet count 335 × 109 /l total bilirubin 0.9 mg/dl, direct bilirubin0.3 mg/dl, alanine aminotransferase 477 IU/L (N (normal range for these laboratory results): 13–40 IU/L), aspartate aminotransferase 214 IU/L (N: 10–42 IU/L), and alkaline phosphatase 346 IU/L (125–240 IU/L). Serum amylase levels and other laboratory findings were normal. The patient was hospitalized and resuscitated with colloids and 2 units of blood suspension after which he was prepared for an
2210-2612/$ – see front matter © 2014 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijscr.2014.01.005
CASE REPORT – OPEN ACCESS A. Rencuzogullari et al. / International Journal of Surgery Case Reports 5 (2014) 142–144
143
3. Discussion
Fig. 1. (a) Pre-operative selective right hepatic angiography (arrow points to the pseudoaneurysm). (b) Arrow pointing of T-tube in intra-operative cholangiogram.
emergency upper gastrointestinal endoscopy. No bleeding source was identified in the stomach and duodenum excluding causes of hemorrhage such as ulcers and malignancy however demonstration of blood flow from the major duodenal papilla raised suspicions of a hemobilia. To confirm diagnosis Doppler ultrasonography and abdominal computer tomography were performed and the presence of a contrast filled sac bulging from the right hepatic artery suggestive of hepatic artery pseudoaneurysm was demonstrated on computed tomography (CT). Selective right hepatic artery angiography was performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery (Fig. 1a). Laparotomy was planned for the treatment as embolization was not available at the time. The patient was taken into the operating theater, the right hepatic artery was ligated and a T-tube was placed after choledocotomy (Fig. 1b), then cholangiography was performed. The biliary system was demonstrated normally on the cholangiogram and consequently the surgery was completed. The patient tolerated the surgery well and made an uneventful recovery; his liver function tests gradually returned to normal. Hematemesis and melena subsided after surgery. On postoperative day 21, cholangiography was repeated and the T-tube was removed due to the normal demonstration observed. The patient was followed for every three months in the first year of post-operation and every six months thereafter for three years. Till date, no late complication has occurred.
Hemobilia is defined as hemorrhage into the biliary tract from an aberrant connection or passageway between a blood vessel (splanchnic circulation) and bile duct.1 The first case was reported by Francis Glisson in 1654, describing the clinical course of a young male patient suffering from severe knife injury to the liver.2 In 1871 Quincke described a case of hemobilia stressing on the classical clinical triad of biliary colic, jaundice, and gastrointestinal bleeding; however, less than 40% of the cases present with the complete triad.1,2 The term hemobilia was first coined by Sandblom in his 1948 paper entitled “Hemorrhage into the Biliary Tract Following Trauma: Traumatic Hemobilia”. Hepatic artery aneurysm and liver trauma causing hemobilia major-massive and life threatening bleeding3–5 are known to be the most common causes of this pathologic vascular-biliary connection. Occasional cases in the current literature have reported an association between hemobilia and cholelithiasis, hepatic abscesses,6 acalculous inflammatory conditions (ascariasis,7 cholecystitis/cholangitis) and neoplasms. Recent years have seen an increase in iatrogenic causes of hemobilia with rates varying from 1% with liver biopsy8 or 4% with trans-hepatic cholangiography9 to 14% with transhepatic drainage,10 40–85% during hepatobiliary surgeries5–7 and less commonly laparoscopic cholecystectomy. Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors.11 Upper GI endoscopy is the diagnostic modality of choice since besides ruling out other causes of hemorrhage, can demonstrate blood flow from the major duodenal papilla making recognition CT reveal dilatation of bile ducts with blood within the ducts and gall bladder. Hemobilia may result in CT findings of mixed or uniform high attenuation blood within the gallbladder lumen just as gallstones, vicarious excretion of intravenous contrast, biliary sludge, and milk of calcium bile. The awareness of the attending surgeon should be drawn to these during the differential diagnostic work up of hemobilia on CT.12–15 In previous years, patients with hemobilia needed conventional angiography to look for a suspected vascular abnormality, such as pseudoaneurysm however with the advents of the multidetector CT (MDCT) and advancements in 3D imaging software in the form of volume rendering; today CT is the preferred choice as a primary vascular imaging technique for hemobilia evaluation. CT angiography using MDCT is fast replacing catheter arteriography for diagnosis of pseudoaneurysms and the latter is now used for therapeutic procedure guidance only.15 Despite recent advances in imaging modalities and techniques, selective right hepatic angiography remains vital in the diagnosis of upper gastrointestinal hemorrhage following laparoscopic cholecystectomy. Embolization offers the advantage of minimally invasive treatment in hemodynamically unstable patients, permits distal as well as proximal control of the hepatic artery, and is an effective treatment for this potentially life-threatening complication.16 Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure. Depending on the etiology of hemobilia, surgery involves direct exploration of the liver with possible hepatic resection, ligation and/or ballooning of the bleeding site by endoscopic intervention, aneurysm excision, cholecystectomy, and relief of bile duct obstruction. The period between establishment of diagnosis and surgical intervention in the absence of embolization as a treatment choice is
CASE REPORT – OPEN ACCESS 144
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critical and should be managed carefully by the attending surgeon. In conclusion, patients undergoing laparoscopic cholecystectomy should be observed with respect to complications in the post-operative course. In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients. Conflict of interest None. Funding None. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request Author contributions Patient management and surgery were done by Ahmet Rencuzogullari, Tolga Akcam, Kubilay Dalci and Abdullah Ulku. The literature was reviewed by Emir Charles Roach. Emir Charles Roach and Kubilay Dalci were involved in the decision making process. The manuscript was drafted and edited by all authors.
References 1. Sandblom P. Hemobilia (biliary tract hemorrhage): history, pathology, diagnosis, treatment. Springfield, IL: Charles C. Thomas; 1972. 2. Golich J, Rilinger N, Brado M, Huppert P, Vogel J, Siech M, et al. Non-operative management of arterial liver hemorrhages. Eur Radiol 1999;9(1):85–8. 3. Glisson F. Anatomia hepatis. 1st ed. Amsterdam: Janssonium and Weyerstraten; 1654. 4. Yoshida J, Donahue PE, Nyhus LM. Hemobilia review of recent experience with a worldwide problem. Am J Gastroenterol 1987;82:448–53. 5. Green MHA, Duell RM, Johnson CD, Jamieson NV. Haemobilia. Br J Surg 2002;88(December (6)):773–86. 6. Otah E, Cushin BJ, Rozenblit GN, Neff R, Otah KE, Cooperman AM. Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg 2002;137(1):55–9. 7. Hofmann AF. Bile acids: the good, the bad, and the ugly. News Physiol Sci 1999;14(February):24–9. 8. Lee SP, Tasman-Jones C, Wattie WJ. Traumatic hemobolia: a complication of percutaneous liver biopsy. Gastroenterology 1977;72:941–4. 9. Cahow CE, Burrell M, Greco R. Hemobilia following percutaneous transhepatic cholangiography. Am Surg 1977;185:235–41. 10. Monden M, Okamura J, Kobayashi N, Shibata N, Horikawa S, Fujinmoto T, et al. Hemobilia after percutaneous tranhepatic biliary drainage. Arch Surg 1980;115:161. 11. Curet P, Baumer R, Rocher A, Grellet J, Mercaider M. Hepatic hemobilia of traumatic or iatrogenic origin: recent advances in diagnosis and therapy, review of the literature 1976 to 1981. World J Surg 1984;8:2–8. 12. Cattan P, Cuillerier E, Cellier C, Cuenod CA, Roche A, Landi B, et al. Hemobilia caused by a pseudoaneurysm of the hepatic artery diagnosed by EUS. Gastrointest Endosc 1999;49:252–5. 13. Madanur MA, Battula N, Sethi H, Deshpande R, Heaton N, Rela M. Pseudoaneurysm following laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2007;6:294–8. 14. Finley DS, Hinojosa MW, Paya M, Imagawa DK. Hepatic artery pseudoaneurysm: a report of seven cases and a review of the literature. Surg Today 2005;35: 5. 15. Horton KM, Smith C, Fishman EK. MDCT and 3D CT angiography of splanchnic artery aneurysms. AJR Am J Roentgenol 2007;189:641–7. 16. Nicholson T, Travis S, Ettles D, Dyet J, Sedman P, Wedgewood K, et al. Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 1999;22(January (1)):20–4.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy夽 Ahmet Rencuzogullari a,∗ , Alexis K. Okoh b , Tolga A. Akcam a , Emir Charles Roach c , Kubilay Dalci a , Abdullah Ulku a a
Cukurova University School of Medicine, Department of Surgery, Turkey Ankara University School of Medicine, Department of Surgery, Turkey c Cleveland Clinic, Department of Pathobiology, United States b
a r t i c l e
i n f o
Article history: Received 13 November 2013 Received in revised form 3 January 2014 Accepted 9 January 2014 Available online 17 January 2014 Keywords: Laparoscopic cholecystectomy Hemobilia Pseudoaneurysm Right hepatic artery
a b s t r a c t INTRODUCTION: Laparoscopic cholecystectomy has many complications which may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the biliary system. PRESENTATION OF CASE: A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient, Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiography were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed. The patient recovered completely. DISCUSSION: Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure. CONCLUSION: In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients. © 2014 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved.
1. Introduction Laparoscopic cholecystectomy has similar morbidity and mortality in experienced hands with open cholecystectomy. However, many complications may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field. Vascular injuries are a common complication of laparoscopic cholecystectomy. In this case report we are presenting a rare entity: pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the
夽 This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. ∗ Corresponding author at: Cukurova University School of Medicine, Balcali Hospital, Department of General Surgery, Saricam, Adana 01330, Turkey. Tel.: +90 5321798280; fax: +90 3223386432. E-mail addresses: [email protected], [email protected] (A. Rencuzogullari).
biliary system. Our diagnostic approach is described and treatment method alongside current treatment modalities is discussed. 2. Case report A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. The procedure was uneventful with no complication during surgery reported in his records. On examination, he was pale; blood pressure was 90/60 mmHg and pulse rate was 110 bpm. Mild epigastric tenderness and right upper quadrant pain upon palpation were noted. Laboratory investigations revealed the following: hemoglobin 8.5 g/dl, white cell count 8.5 × 109 /l, platelet count 335 × 109 /l total bilirubin 0.9 mg/dl, direct bilirubin0.3 mg/dl, alanine aminotransferase 477 IU/L (N (normal range for these laboratory results): 13–40 IU/L), aspartate aminotransferase 214 IU/L (N: 10–42 IU/L), and alkaline phosphatase 346 IU/L (125–240 IU/L). Serum amylase levels and other laboratory findings were normal. The patient was hospitalized and resuscitated with colloids and 2 units of blood suspension after which he was prepared for an
2210-2612/$ – see front matter © 2014 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijscr.2014.01.005
CASE REPORT – OPEN ACCESS A. Rencuzogullari et al. / International Journal of Surgery Case Reports 5 (2014) 142–144
143
3. Discussion
Fig. 1. (a) Pre-operative selective right hepatic angiography (arrow points to the pseudoaneurysm). (b) Arrow pointing of T-tube in intra-operative cholangiogram.
emergency upper gastrointestinal endoscopy. No bleeding source was identified in the stomach and duodenum excluding causes of hemorrhage such as ulcers and malignancy however demonstration of blood flow from the major duodenal papilla raised suspicions of a hemobilia. To confirm diagnosis Doppler ultrasonography and abdominal computer tomography were performed and the presence of a contrast filled sac bulging from the right hepatic artery suggestive of hepatic artery pseudoaneurysm was demonstrated on computed tomography (CT). Selective right hepatic artery angiography was performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery (Fig. 1a). Laparotomy was planned for the treatment as embolization was not available at the time. The patient was taken into the operating theater, the right hepatic artery was ligated and a T-tube was placed after choledocotomy (Fig. 1b), then cholangiography was performed. The biliary system was demonstrated normally on the cholangiogram and consequently the surgery was completed. The patient tolerated the surgery well and made an uneventful recovery; his liver function tests gradually returned to normal. Hematemesis and melena subsided after surgery. On postoperative day 21, cholangiography was repeated and the T-tube was removed due to the normal demonstration observed. The patient was followed for every three months in the first year of post-operation and every six months thereafter for three years. Till date, no late complication has occurred.
Hemobilia is defined as hemorrhage into the biliary tract from an aberrant connection or passageway between a blood vessel (splanchnic circulation) and bile duct.1 The first case was reported by Francis Glisson in 1654, describing the clinical course of a young male patient suffering from severe knife injury to the liver.2 In 1871 Quincke described a case of hemobilia stressing on the classical clinical triad of biliary colic, jaundice, and gastrointestinal bleeding; however, less than 40% of the cases present with the complete triad.1,2 The term hemobilia was first coined by Sandblom in his 1948 paper entitled “Hemorrhage into the Biliary Tract Following Trauma: Traumatic Hemobilia”. Hepatic artery aneurysm and liver trauma causing hemobilia major-massive and life threatening bleeding3–5 are known to be the most common causes of this pathologic vascular-biliary connection. Occasional cases in the current literature have reported an association between hemobilia and cholelithiasis, hepatic abscesses,6 acalculous inflammatory conditions (ascariasis,7 cholecystitis/cholangitis) and neoplasms. Recent years have seen an increase in iatrogenic causes of hemobilia with rates varying from 1% with liver biopsy8 or 4% with trans-hepatic cholangiography9 to 14% with transhepatic drainage,10 40–85% during hepatobiliary surgeries5–7 and less commonly laparoscopic cholecystectomy. Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors.11 Upper GI endoscopy is the diagnostic modality of choice since besides ruling out other causes of hemorrhage, can demonstrate blood flow from the major duodenal papilla making recognition CT reveal dilatation of bile ducts with blood within the ducts and gall bladder. Hemobilia may result in CT findings of mixed or uniform high attenuation blood within the gallbladder lumen just as gallstones, vicarious excretion of intravenous contrast, biliary sludge, and milk of calcium bile. The awareness of the attending surgeon should be drawn to these during the differential diagnostic work up of hemobilia on CT.12–15 In previous years, patients with hemobilia needed conventional angiography to look for a suspected vascular abnormality, such as pseudoaneurysm however with the advents of the multidetector CT (MDCT) and advancements in 3D imaging software in the form of volume rendering; today CT is the preferred choice as a primary vascular imaging technique for hemobilia evaluation. CT angiography using MDCT is fast replacing catheter arteriography for diagnosis of pseudoaneurysms and the latter is now used for therapeutic procedure guidance only.15 Despite recent advances in imaging modalities and techniques, selective right hepatic angiography remains vital in the diagnosis of upper gastrointestinal hemorrhage following laparoscopic cholecystectomy. Embolization offers the advantage of minimally invasive treatment in hemodynamically unstable patients, permits distal as well as proximal control of the hepatic artery, and is an effective treatment for this potentially life-threatening complication.16 Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure. Depending on the etiology of hemobilia, surgery involves direct exploration of the liver with possible hepatic resection, ligation and/or ballooning of the bleeding site by endoscopic intervention, aneurysm excision, cholecystectomy, and relief of bile duct obstruction. The period between establishment of diagnosis and surgical intervention in the absence of embolization as a treatment choice is
CASE REPORT – OPEN ACCESS 144
A. Rencuzogullari et al. / International Journal of Surgery Case Reports 5 (2014) 142–144
critical and should be managed carefully by the attending surgeon. In conclusion, patients undergoing laparoscopic cholecystectomy should be observed with respect to complications in the post-operative course. In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients. Conflict of interest None. Funding None. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request Author contributions Patient management and surgery were done by Ahmet Rencuzogullari, Tolga Akcam, Kubilay Dalci and Abdullah Ulku. The literature was reviewed by Emir Charles Roach. Emir Charles Roach and Kubilay Dalci were involved in the decision making process. The manuscript was drafted and edited by all authors.
References 1. Sandblom P. Hemobilia (biliary tract hemorrhage): history, pathology, diagnosis, treatment. Springfield, IL: Charles C. Thomas; 1972. 2. Golich J, Rilinger N, Brado M, Huppert P, Vogel J, Siech M, et al. Non-operative management of arterial liver hemorrhages. Eur Radiol 1999;9(1):85–8. 3. Glisson F. Anatomia hepatis. 1st ed. Amsterdam: Janssonium and Weyerstraten; 1654. 4. Yoshida J, Donahue PE, Nyhus LM. Hemobilia review of recent experience with a worldwide problem. Am J Gastroenterol 1987;82:448–53. 5. Green MHA, Duell RM, Johnson CD, Jamieson NV. Haemobilia. Br J Surg 2002;88(December (6)):773–86. 6. Otah E, Cushin BJ, Rozenblit GN, Neff R, Otah KE, Cooperman AM. Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg 2002;137(1):55–9. 7. Hofmann AF. Bile acids: the good, the bad, and the ugly. News Physiol Sci 1999;14(February):24–9. 8. Lee SP, Tasman-Jones C, Wattie WJ. Traumatic hemobolia: a complication of percutaneous liver biopsy. Gastroenterology 1977;72:941–4. 9. Cahow CE, Burrell M, Greco R. Hemobilia following percutaneous transhepatic cholangiography. Am Surg 1977;185:235–41. 10. Monden M, Okamura J, Kobayashi N, Shibata N, Horikawa S, Fujinmoto T, et al. Hemobilia after percutaneous tranhepatic biliary drainage. Arch Surg 1980;115:161. 11. Curet P, Baumer R, Rocher A, Grellet J, Mercaider M. Hepatic hemobilia of traumatic or iatrogenic origin: recent advances in diagnosis and therapy, review of the literature 1976 to 1981. World J Surg 1984;8:2–8. 12. Cattan P, Cuillerier E, Cellier C, Cuenod CA, Roche A, Landi B, et al. Hemobilia caused by a pseudoaneurysm of the hepatic artery diagnosed by EUS. Gastrointest Endosc 1999;49:252–5. 13. Madanur MA, Battula N, Sethi H, Deshpande R, Heaton N, Rela M. Pseudoaneurysm following laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2007;6:294–8. 14. Finley DS, Hinojosa MW, Paya M, Imagawa DK. Hepatic artery pseudoaneurysm: a report of seven cases and a review of the literature. Surg Today 2005;35: 5. 15. Horton KM, Smith C, Fishman EK. MDCT and 3D CT angiography of splanchnic artery aneurysms. AJR Am J Roentgenol 2007;189:641–7. 16. Nicholson T, Travis S, Ettles D, Dyet J, Sedman P, Wedgewood K, et al. Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 1999;22(January (1)):20–4.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
