title: A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula.
abstract: INTRODUCTION Cystic artery pseudoaneurysms and cholecystoenteric fistulae represent two rare complications of gallstone disease. PRESENTATION OF CASE An 86 year old male presented to the emergency department with obstructive jaundice, RUQ pain and subsequent upper gastrointestinal bleeding. Upper GI endoscopy revealed bleeding from the medial wall of the second part of the duodenum and a contrast-enhanced computed tomography scan revealed a cystic artery pseudoaneurysm, concurrent cholecystojejunal fistula and gallstone ileus. This patient was successfully managed surgically with open subtotal cholecystectomy, pseudoaneurysm resection and fistula repair. DISCUSSION To date there are very few cases describing haemobilia resulting from a bleeding cystic artery pseudoaneurysm. This report is the first to describe upper gastrointestinal bleeding as a consequence of two synchronous rare pathologies: a ruptured cystic artery pseudoaneurysm causing haemobilia and bleeding through a concurrent cholecystojejunal fistula. CONCLUSION Through this case, we stress the importance of accurate and early diagnosis through ultra- sonography, endoscopy, and contrast-enhanced CT imaging and emphasise that haemobilia should be included in the differential diagnosis of anyone presenting with upper gastrointestinal bleeding. We have demonstrated the success of surgical management alone in the treatment of such a case, but accept that consideration of combined therapeutic approach with angiography be given in the first instance, when available and clinically indicated.
authors.affiliation: Department of General Surgery, Royal Hampshire County Hospital, Hampshire Hospitals NHS Foundation Trust, Winchester, SO22 5DJ, UK. Electronic address: michaelglaysher@me.com.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Glaysher
authors.affiliation: Department of General Surgery, Royal Hampshire County Hospital, Hampshire Hospitals NHS Foundation Trust, Winchester, SO22 5DJ, UK. Electronic address: dwood@doctors.org.uk.
authors.forename: David
authors.initials: D
authors.lastname: Cruttenden-Wood
authors.affiliation: Department of General Surgery, Royal Hampshire County Hospital, Hampshire Hospitals NHS Foundation Trust, Winchester, SO22 5DJ, UK. Electronic address: karoly.szentpali@hhft.nhs.uk.
authors.forename: Karoly
authors.initials: K
authors.lastname: Szentpali
keywords: Cholecystoenteric fistula; Cholecystojejunal fistula; Cystic Artery; Pseudoaneurysm