Case presentation 2019.6.7 부산대학병원 한 성 용

F/29 P.Hx) HT / DM / Hepa / Tbc - / - / - / - S.Hx) smoking : - C.C) Hematochezia, RUQ pain P.I) 내원 2일전부터 시작된 혈변 (하루 3~5회) 및 우상복부 통증으로 내원 P.Hx) HT / DM / Hepa / Tbc - / - / - / - cholecystitis : laparoscopic cholecystectomy (18.10.17) S.Hx) smoking : - alcohol : - F.Hx) 모 (대장암) 110129936 2012.10.29 1-18 CTx day15

Review Of System [Constitutional systems] [HEENT] General weakness/Fatigue/Weight loss/Weight gain/Chilling/Fever (-/-/-/-/-/-) [HEENT] Headache/Dizziness/Sore throat (-/-/-) [Cadiovascular & Respiratory] Chest pain/Dyspnea/Palpitation (-/-/-) Cough/Sputum/Wheeze/Hemoptysis (-/-/-/-) [Gastrointestinal] Anorexia/Nausea/Vomiting/Diarrhea/Constipation (-/-/-/-/-) Abd. pain/Jaundice (+/-) [Genitourinary] Dysuria/Frequency/Urgency/Hematuria (-/-/-/-) [Musculoskeletal] Arthralgia/Joint swelling/Stiffness (-/-/-)

PHYSICAL EXAMINATION GA / GC Chest HEENT Abdomen Extremities acute. ill app. Good condition HEENT Not anemic conjunctivae anIcteric sclera Not dehydrated tongue Not engorged neck v. No CLN, SCLN enlargement Chest CBS /s r RHB /s m Abdomen Not distended RUQ abd. T/RT +-/- Audible BS Extremities No Pitting edema

Lab finding(18.11.13) Biochemistry CBC WBC 5270 /mm3 neutrophil 68.9 % Hb 8.0 g/dL PLT 155 103/mm3 Amy/Lip 93.8/36.7 IU/L GGT 284 CRP 0.05 mg/dL PT(INR) /aPTT 13.2(1.16) /30.4 sec Biochemistry AST/ALT 331/163 IU/L ALP/LDH 146/450 TB/DB 1.16/ mg/Dl TP/Alb 8.06/4.32 gm/dL BUN/Cr 13.0/0.48 TC/UA /4.0 Ca/P 8.8/3.56 Na/K 138.4/4.46 mEq/L

19.11.13 CT abdomen 1. S/P Cholecystectomy. 2. Interval increased IHD dilatation, compared to the previous CT Abdomen(2018.10.13).        -- with several IHD stones and CBD stone or sludge 3. Inhomogeneous density of liver. #2,3 : Hepatico-cholangitis 4. No evidence of active bleeding in GI tract.

18.11.14 EGD/S-결장경

Progression Lab f.u 11.14 11.15 11.16 Hb 6.8=> 수혈후 9.6 9.4 10.2 AST 318 118 68 ALT 215 133 100 TB 1.13 0.77 0.48 11월 13일 내원 11월 14일 Hb 추가 저하 발생 11월 14일 EGD, S-결장경 검사 hemobilia 가능성도 고려하였으나, EGD당시 ampulla주위 혈액이 확인되지 않음 11월 16일 colonoscopy 검사 이후 discharge 11월 17일 hematochezia 다시 발생하여 ER로 내원 Hb 9.5

18.11.16 colonoscopy

18.11.17 CT abdomen 1. no change of hyperintense content in the dilatated IHD and EHD   --> DDx: 1. suspicious hemobilia            2. R/O bile duct stone or sludge 2. no change of a few tiny hyperintense leions in both lobes of the liver   --> DDx: suspicious IHD stone 3. otherwise no remarkable finding in abdomen and pelvis   -- no definite evidence of active bleeding

18.11.19 ERCP, lab f.u 11.17 11.19 Hb 9.5 7.4 AST 150 152 ALT 115 113 TB 1.58 1.75

18.11.19 Angiography

18.11.26 ERCP

Progression Lab 류마티스내과 협진 류마티스질환 중 pseduoaneurysm이 올 수 있는 것으로 베쳇병이 있는데 이에 대한 증상은 없는 것으로 보입니다 FANA ANCA Anti RNP Anti-centromere Ab Anti-SCL-70 Anti-dsDNA 1:40이하 C/P -/- -

Hepatic artery pseudoaneurysm Case review Hepatic artery pseudoaneurysm

Laparoscopic cholecystectomy Bile-duct injury(BDI) : 0.2-0.6% Vascular injury : rare, but can occur in ≈25% of patients who suffer a BDI Over bleeding from hepatic a. hepatic portal v. Delayed Hepatic infarction Liver abscess from inadvertent ligation of the hepatic artery symptomatic pseudoaneurysm involving the right hepatic artery

Pseudoaneurysm Presentation Mechanism High risk patients Clinically unpredictable course Present weeks to months after the index LC Most patients present within 6 weeks Mechanism mechanical injury at dissection or diathermy injury Secondary injury possibly occurs from bile leak and infection. Metal clips in direct contact High risk patients BDI Bile leak Infection after LC

Treatment First-line treatment selective hepatic arterial angiography and embolisation Surgical exploration is not the initial recommended therapeutic option Angioembolisation fails or if it is not possible logistically Percutaneous image-guided thrombin injection EUS guided injection and obliteration of selected visceral pseudoaneurysm Surgical options (ligation of feeding vessels) Any patient with a history of a BDI who presents with gastrointestinal bleeding, hypotension or otherwise unexplained abdominal pain should be investigated for a possible pseudoaneurysm.