Gallbladder ulcer erosion into the cystic artery: a rare cause ofupper gastro-intestinal bleeding Case report
© Ben-Ishay et al; licensee BioMed Central Ltd. 2010
Received: 9 January 2010
Accepted: 12 March 2010
Published: 12 March 2010
Intra luminal gallbladder bleeding is a rare cause of hemobilia that results in upper gastro-intestinal bleeding. In this case report we present a patient who presented with melena and eventually was diagnosed as bleeding from an ulcer in the gallbladder which was induced by gallstones and eroded into the cystic artery. Surgery revealed perforation of gallbladder which was the result of a pressure sore induced by a second gallstone.
Bleeding into the biliary tree or Hemobilia is a rare cause for upper gastro-intestinal bleeding that was first described by Francis Glison in 1654 . Most commonly hemobilia is the result of trauma or investigatory interventions but inflammation, vascular malformation, malignancy and coagulopathy were also described as potential causes of hemobilia. A gallbladder ulcer eroding into the cystic artery is very rare, and only a handful of case reports of this entity are reported in the literature. When diagnosed, angioembolization followed by cholecystectomy is the recommended treatment.
We present a patient who was admitted due to melena and eventually was diagnosed as having hemobilia resulting from bleeding into the lumen of the gallbladder due to erosion of the cystic artery by gallstones.
On exploration of the resected specimen, two large gallstones were found, and a 0.5 cm ulcer was observed in the gallbladder wall.
Histopathologic examination was consistent with acute and chronic cholecystitis involving all layers of the organ that resulted in the formation of an ulcer with rupture of a pseudoaneurysm of the cystic artery.
The patient was discharged on the fourteenth post operative day; the drains were removed during the first postoperative outpatient clinic encounter and patient recovered uneventfully.
Discussion and Conclusions
Spontaneous intra-cholecystic bleeding is a rare occurrence which was described in patients with gallstones  gallbladder malignancy  and patients receiving anticoagulant therapy . Bleeding as a result of an ulcer eroding into an otherwise normal cystic artery or pseudoaneurysm of the cystic artery is rare [5–7]. When diagnosed, angioembolization of the bleeding cystic artery was suggested as the treatment of choice for bleeding control. In this report, we presented a patient who had large gallstones leading to the formation of a decubitus ulcer that eroded into the cystic artery with the formation of a pseudoaneurysm that ruptured and bled into the lumen of the gallbladder causing hemobilia with subsequent overt upper gastro-intestinal hemorrhage. A large gallbladder peroration, also presumed to be a result of a second decubitus ulcer was revealed during the surgical exploration.
Upper gastro-intestinal bleeding should be addressed promptly. If hemobilia is diagnosed and large stones in the gallbladder are detected, bleeding from a gallbladder ulcer should be ruled out. If angioembolization is elected, this should be followed immediately with surgery as the clinical set-up of bleeding due to gallstones might suggest a more complicated gallbladder disease than previously suspected.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor in chief of this journal.
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