Pseudoaneurysm of the cystic artery: an uncommon cause of lower gastrointestinal bleeding with concurrent cholecystocolonic fistula.

Pseudoaneurysm of the cystic artery is a rare complication. Its presentation with lower gastrointestinal bleeding and cholecystocolonic fistulae is even rare. Most of the reported cases are iatrogenic and develop secondary to liver biopsy, laparoscopic cholecystectomy, trauma, malignancy and inflammation in the hepatobiliary (following cholecystitis) and pancreatic system. A 61-year-old male presented to the emergency department with upper right quadrant abdominal pain, hypotension, haematemesis, fresh blood per rectum and cardiovascular instability associated. He was resuscitated with intravenous fluids and blood transfusions. Then he underwent an upper gastrointestinal endoscopy, which was normal. The emergency abdominal contrast-enhanced computed tomography (CT) scan was performed, demonstrating abnormal structural findings in the gallbladder, with a thick-walled and inflamed, cholelithiasis, and involvement of the fat around the gallbladder. (Fig. 1a-b), a 22 mm pseudoaneurysm emanating from the cystic artery (Fig 1c) and concurrent cholecystocolonic (colon transverse) fistula and gallstone ileus. The patient after resuscitation underwent selective visceral angiography and coil embolization of the cystic artery pseudoaneurysm, by selective catheterization of the hepatic artery and supraselective catheterization of the cystic artery. (Fig. 1d). During the same admission, this patient was managed surgically laparotomy, the gallbladder was inflamed, perforated, and was found to be adherent to the surrounding tissue. Following dissection of the adhesions, division of these exposed a cholecystocolonic (colon transverse) fistula containing clotted blood that was extending into the gallbladder. Following identification of the cystic artery and cystic duct, both were ligated. Cholecystectomy was performed, the pseudoaneurysm of the cystic artery was extirpated, and finally resection of the transverse colon with terminal jejunostomy in the right iliac fossa.

This case to describe lower gastrointestinal bleeding as a consequence of two rare synchronous pathologies: a ruptured of pseudoaneurysm of the cystic artery following cholecystitis, causing haemobilia and bleeding through a concurrent cholecystocolonic fistula.

Through this case, we stress the importance of accurate and early diagnosis through ultrasonography,endoscopy, and contrast-enhanced CT imaging and emphasize that haemobilia for pseudoaneurysm of the cystic artery, should be included in the differential diagnosis of anyone presenting with clinical signs of cholecystitis and lower gastrointestinal bleeding.

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