1. Case presentation
부산대학병원
한 성 용

2. 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 ( )
S.Hx) smoking : -
alcohol : -
F.Hx) 모 (대장암)
CTx day15

3. 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 (-/-/-)

4. 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

5. 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

6. CT abdomen
1. S/P Cholecystectomy. 2. Interval increased IHD dilatation, compared to the previous CT Abdomen( ).        -- 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.

7. EGD/S-결장경

8. 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

9. colonoscopy

10. CT abdomen
1. no change of hyperintense content in the dilatated IHD and EHD   --> DDx: 1. suspicious hemobilia            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

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

12. Angiography

13. ERCP

14. 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 -/- -

15. Hepatic artery pseudoaneurysm
Case review
Hepatic artery pseudoaneurysm

16. Laparoscopic cholecystectomy
Bile-duct injury(BDI) : %
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

17. 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

18. 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.