SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 20 CASE SERIES the intrahepatic branches of the right and left hepatic arteries. 2 Cystic artery pseudoaneurysm secondary to acute cholecystitis (CAPAC) itself is even rarer accounting for 25 % of haemobilia causes 1,2 with Quincke’s triad being present in just over half of the reported cases. 3 To attribute pseudoaneurysm formation as secondary to cholecystitis there can be no prior cholecystectomy or intervention. The primary mechanism of CAPAC has been proposed to be due to local inflammation from cholecystitis which leads to vessel infiltration and subsequent pseudoaneurysm formation. 4,5 Underlyingcomorbidities,specifically atherosclerosis and anti-thrombotic drug use have been theorized to further contribute to this process. 2 After pseudoaneurysm formation, the natural progression of inflammatory process results in fistulisation. After bleeding into the gallbladder the blood then passes into the bile duct and into the duodenum via the ampulla of Vater or even the fistula tract giving rise to overt OGIB. 4 Upper endoscopy is usually negative as the bleeding stops and starts and is occurring from the ampulla which is better viewed with an ERCP scope if the condition is suspected. Case 2: Small bowel ulceration The second patient was a 35 year old male with no documented co-morbidities. He presented with an acute GI bleed and hypovolemic shock. After stabilization with blood products, he had a gastroscopy which showed no evidence of an active or recent upper GI bleeding. Due to clinical evidence of ongoing bleeding, he had a CT Angiogram performed which revealed active contrast extravasation within the lumen of a loop of jejunum (Figure 2a). A DSA was performed, which identified an ileal branch of the superior mesenteric artery which was responsible for the bleed. Attempts at cannulating this vessel with a view for embolotherapy were unsuccessful and he was transferred to theatre for a laparotomy. A decision had been made to leave the guide wire which was close to the haemorrhaging vessel in situ to aide intra operative localization. Intra operatively a small bowel lesion was identified approximately 90cm from the ileo-caecal valve with macroscopic features of granulomatous inflammation. A segmental resection and end to end anastomosis was performed. An on table intra-operative small bowel endoscopy was performed prior to resection to both confirm that the lesion was responsible for bleeding and exclude other lesions (Figure 2b). On review of the resected segment a visible vessel with an overlying clot was seen within an ulcer (Figure 2c). Formal histology confirmed the presence of granulomatous inflammation. Further workup identified that he was HIV positive and had pulmonary tuberculosis. He was started on an appropriate regimen for disseminated tuberculosis and referred for HIV counselling and treatment. Small bowel ulceration (SBU) causing overt bleeding is a rare entity with angiodysplasias being responsible for the majority of Figure 1e. Intra operative picture during open cholecystectomy for CAPAC. Post closure of the choleduodenal fistula (arrow) Figure 2a. CT Abdomen axial view. Contrast extravasation can be seen within loops of small bowel (arrow) Figure 2b. Intra operative endoscopy. The scope was introduced after the segmental resection of the lesion responsible for bleeding. Telescoping the small bowel on the scope allowed for complete examination both proximally and distally. Figure 2c. Macroscopic examination of Small Bowel Ulceration causing bleeding. Remnant of clot is visible in area of ulcer (1) and a visible vessel (2)