SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 19 CASE SERIES Solutions from a potpourri of obscure overt GI bleeds Introduction Both upper and lower gastrointestinal bleeding are well documented and managed entities. Occasionally rare causes of bleeding occur at sites not accessible by gastroscopy and colonoscopy and may elude the keenest of clinicians. We present the following case series and highlight the diagnostic and management challenges posed and suggest an approach to the overt subcategory of obscure GI bleeding. Case 1: Cystic artery pseudoaneurysm secondary to acute cholecystitis A 70 year old female presented to our service with signs and symptoms of acute upper GI bleeding. Her only symptom was melena stools her Hb was 9,0 g/dl. Upper and lower endoscopy did not reveal a source of bleeding. Due to her haemodynamic stability, she was managed conservatively. Two days after colonoscopy she was noted to be clinically jaundiced. A CT scan was performed and showed complicated cholecystitis with clot filling almost the entire biliary tree (Figure 1a) as well as an arterial blush at the cystic artery (Figure 1b). A DSA was performed, and a covered stent was deployed in the right hepatic artery across the cystic artery take off and the haemorrhage was controlled (Figure 1c). She was discharged well but represented a month later with a hemodynamically unstable GI bleed. Consideration was given to repeat the DSA and possible right hepatic artery embolization but that would have left the cholecystitis untreated. As such she was booked for an emergency cholecystectomy. The cholecystectomy was started laparoscopically but converted to an open procedure due to brisk bleeding (Figure 1d). In retrospect one would likely start this case as an open procedure. The bleeding cystic artery false aneurysm was easily controlled without the need for a Pringle manoeuvre or control of the right hepatic artery. Cholecystectomy was successfully performed along with closure of a small cholecystoduodenal fistula (Figure 1e). Haemobilia accounts for less than 1% of OGIB. The classical symptom and signs described as Quincke’s triad are right upper quadrant pain, jaundice and gastrointestinal haemorrhage, but are not always present. 1 The main causes of haemobilia are trauma, liver biopsy or stent placement. These usually involve Correspondence Dr Terron Govender email: terron.govender@uct.ac.za T Govender 1 , S Rayamajhi 1 , S Thomson 2 , C Kloppers 1 1 Acute Care Surgery Unit, University of Cape Town and Groote Schuur Hospital 2 Division of Medical Gastroenterology, University of Cape Town and Groote Schuur Hospital Figure 1a. CT Abdomen axial view. Gallbladder filled with blood/clot (1) and air locules (2) Figures 1b,c. Digital Subtraction Angiography (B) Contrast extravasation in region of cystic artery (arrow) and (C) Stent deployed with control of haemorrhage as evidenced by the absence of contrast extravasation. Figure 1d. Intra operative picture during Laparoscopic Cholecystectomy for CAPAC. During dissection in Calots Triangle, brisk bleeding (stream of blood within box) was encountered from Cystic Artery (Arrow)