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• W2034930165 abstract "Question: A 46-year-old man with primary sclerosing cholangitis (PSC) diagnosed in 2009 was admitted with hepatic decompensation secondary to intrahepatic sepsis (Model for End-Stage Liver Disease [MELD] score, 20). He had previously been assessed and listed for liver transplantation in August 2009. His admission was complicated with multiple episodes of sepsis, cholangitis, and gastrointestinal (GI) bleeding. He had required admission to the intensive care unit on 3 occasions for organ support. Episodes of GI bleeding from esophageal varices and a duodenal ulcer during his admission had been managed endoscopically. Given his clinical deterioration he was priority listed for liver transplantation (MELD score, 24). In the early hours of the morning during week 12 of his admission, he had a catastrophic GI bleed with significant hemodynamic instability. He had a 10-U blood transfusion over the next 6 hours and stabilized hemodynamically. Emergency upper GI endoscopy showed torrential bleeding from the second part of the duodenum not amenable to endoscopic therapy. There was no evidence of bleeding from esophageal varices or a duodenal ulcer. He proceeded to a mesenteric angiogram (Figure A), which identified the site of bleeding. Computed tomography (Figure B) demonstrated the underlying cause of bleeding identified on the mesenteric angiogram. What was the underlying cause of GI bleed and which vessel was bleeding? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. GI bleeding was arising from an avulsed cystic artery owing to a ruptured gallbladder. The angiogram (Figure C) shows a ruptured cystic artery and extravasation of blood (Figure C, arrow). Attempts were made to embolize this vessel. Figure D is a venous phase CT scan demonstrating hemorrhage around a ruptured gallbladder (arrow). A solitary gallstone is seen lying outside the gallbladder. Figure E is an arterial phase CT scan demonstrating an ischemic liver, which occurred after massive GI blood loss. Hemobilia is due to a communication between the splanchnic circulation and the biliary tree. The most common causes are iatrogenic or traumatic liver injury, which accounts for approximately 50% of cases.1Demyttenaere S.V. Hassanain M. Halwani Y. et al.Massive hemobilia.Can J Surg. 2009; 52: E109-E110PubMed Google Scholar, 2Tan P.S. Teo E.K. Fock K.M. et al.Massive obscure-overt upper gastrointestinal bleeding secondary to hemobilia.Endoscopy. 2009; 41: E294-E295Crossref PubMed Scopus (1) Google Scholar Other etiologies include malignancy, arteriobiliary or arterioportal fistula, and pseudoaneurysm of the hepatic arteries. Hemobilia owing to a pseudoaneurysm of the cystic artery from cholecystitis has been reported.3Akatsu T. Tanabe M. Shimizu T. et al.Pseudoaneurysm of the cystic artery secondary to cholecystitis as a cause of hemobilia: report of a case.Surg Today. 2007; 37: 412-417Crossref PubMed Scopus (32) Google Scholar Spontaneous rupture of the gallbladder without preceding trauma or postoperatively is exceedingly rare. Spontaneous rupture of the gallbladder leading to bleeding from the cystic artery has not previously been reported in the literature. In this case, it is possible that an empyema near the gallbladder may have led to the rupture of the gallbladder and avulsion of the cystic artery." @default.
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• W2034930165 date "2011-05-01" @default.
• W2034930165 modified "2023-09-25" @default.
• W2034930165 title "Massive Gastrointestinal Bleed in a Patient With Primary Sclerosing Cholangitis" @default.
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• W2034930165 doi "https://doi.org/10.1053/j.gastro.2010.03.074" @default.
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