Fistulizing Cystic Artery Pseudoaneurysm Masquerading as a Bleeding Submucosal Duodenal Lesion : ACG Case Reports Journal

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Fistulizing Cystic Artery Pseudoaneurysm Masquerading as a Bleeding Submucosal Duodenal Lesion

Schell, Trevor L. MD1; Hoversten, Patrick MD2; Gaumnitz, Eric MD2

Author Information
doi: 10.14309/crj.0000000000000864
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CASE REPORT

A 73-year-old man presented to the emergency department with 2 weeks of melena and was found to have blood loss anemia with hemoglobin 5.6 g/dL. The patient underwent laparoscopic cholecystectomy 2 months earlier. Esophagogastroduodenoscopy revealed a possible submucosal lesion vs a region of extrinsic compression in the duodenum with an overlying focal area of oozing erosion (Figure 1). One hemostatic clip was placed, and the lesion was biopsied using a bite-in-bite technique. Abdominal computed tomography revealed a collection of high-attenuation material within the biliary fossa, adjacent to the duodenum and hemostatic clip (Figure 2). Given concern for a vascular lesion, abdominal computed tomography angiogram was obtained, which revealed a 7 cm cystic artery stump pseudoaneurysm (CAP) exerting mass effect on the duodenum (Figure 3). Angiography with coil embolization and ultrasound-guided percutaneous thrombin injection was performed; bleeding resolved; and the patient was discharged without evidence of complication to date (Figure 4). Duodenal biopsies demonstrated normal duodenal mucosa. CAP is a very rare complication of cholecystectomy and is an even rarer cause of upper gastrointestinal bleeding.1 This case demonstrates the importance of early recognition in the management of CAP complicated by upper gastrointestinal bleeding, being that the preferred therapeutic approach is endovascular as opposed to endoscopic.

F1
Figure 1.:
Esophagogastroduodenoscopy demonstrating a duodenal lesion with overlying erosion, which was subsequently clipped and biopsied with a bite-in-bite technique.
F2
Figure 2.:
Abdominal computed tomography showing a collection of high-attenuation material within the biliary fossa, adjacent to the duodenum and hemostatic clip.
F3
Figure 3.:
computed tomography angiogram demonstrating a 7 cm cystic artery stump pseudoaneurysm with mass effect on the duodenum.
F4
Figure 4.:
Angiography showing contrast filling of a large pseudoaneurysm within the gallbladder fossa, adjacent to numerous surgical clips.

DISCLOSURES

Author contributions: TL Schell wrote the manuscript, edited the manuscript, reviewed the literature, revised the manuscript for intellectual content, and approved the final manuscript. P. Hoversten edited the manuscript, provided the images, revised the manuscript for intellectual content, and approved the final manuscript. E. Gaumnitz edited the manuscript, revised the manuscript for intellectual content, approved the final manuscript, and is the article guarantor.

Financial disclosure: None to report.

Previous presentation: Not applicable.

Informed consent was obtained for this case report.

REFERENCE

1. Lampropoulos C, Markopoulos G, Tsochatzis S, et al. Symptomatic pseudoaneurysms following laparoscopic cholecystectomy: Focus on an unusual and dangerous complication. J Minim Access Surg. 2021;17(4):450–7.
© 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.