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ANZMOSS - ANZGOSA 2020 Virtual Conference
ANZMOSS – ANZGOSA 2020 Virtual Conference
ANZMOSS - ANZGOSA 2020 Virtual Conference

Ruptured right hepatic pseudoaneurysm from Mirizzi syndrome with simultaneous cholecystoduodenal fistula: A rare complication of gallstone disease

Presented is a rare case of Mirizzi syndrome causing right hepatic artery pseudoaneurysm and subsequent rupture, leading to melaena through a concurrent cholecystoduodenal fistula. This is the only such case in the literature. 
An 82-year old man presented with right upper quadrant pain, jaundice and vomiting. Computed tomography (CT) revealed marked gallbladder inflammation and a large gallstone in the fundus. A thick-walled collection between the gallbladder fundus and duodenum was concerning for cholecystoduodenal fistula. Magnetic resonance cholangiopancreatography (MRCP) also showed loss of normal tissue planes between the fundus and duodenum. MRCP additionally demonstrated Type I Mirizzi syndrome, with further impacted gallstone at the gallbladder neck causing extrinsic compression of the common hepatic duct and intrahepatic duct dilatation. There was mixed signal fluid with a possible mass within the gallbladder lumen, due to either haemorrhage or primary malignancy.
The patient subsequently developed multiple episodes of melaena with significant transfusion requirement. Upper endoscopy revealed an oozing, ulcerative lesion in the second part of the duodenum, likely the site of cholecystoduodenal fistula. 
At laparoscopy, decision was made to perform subtotal cholecystectomy due to dense adhesions. Needle decompression of the gallbladder to facilitate retraction revealed frank blood within. A large stone was removed and subsequent brisk, pulsatile, arterial bleeding adjacent to the cystic duct opening required control with packing and sutures. Subsequent formal angiography revealed a large 11.5mm right hepatic artery pseudoaneurysm, requiring transarterial embolization with coiling.
This case highlights the importance of considering pseudoaneurysm in patients presenting with gallstone disease and upper gastrointestinal bleeding. Identification and appropriate treatment of biliary-vascular fistulas with preoperative angioembolisation can avoid major arterial bleeding during cholecystectomy. 
Associate Professor David Cavallucci - Royal Brisbane and Women's Hospital - Department of HPB Surgery, Associate Professor Nicholas O'Rourke - Royal Brisbane and Women's Hospital - Department of HPB Surgery, Dr Richard Bryant - Royal Brisbane and Women's Hospital - Department of HPB Surgery, Dr Roger Bain - Royal Brisbane and Women's Hospital - Department of Interventional Radiology, Dr Peadar S Waters - Royal Brisbane and Women's Hospital, and Dr Bianca Kwan - Royal Brisbane and Women's Hospital