NON-TRAUMATIC HEPATIC

PSEUDOANEURYSM:
A LOCAL CASE

A Case Report
Submitted to the Department of Diagnostic Imaging and Radiologic Sciences
Corazon Locsin Montelibano Memorial Regional Hospital

By:
Arrabella R. Tantengco, MD
First Year Radiology Resident
arrabellatantengco@gmail.com
639177240187
ABSTRACT

Hepatic artery pseudoaneurysm (HAP) is an unusual but potentially life

threatening vascular entity, mainly caused by acute or chronic hepatic artery injuries. It
usually follows blunt or penetrating injuries and interventional radiological procedures.
Non-traumatic pseudoaneurysm of hepatic artery is reported very rarely, caused by
arteriosclerosis, polyarteritis nodosa, acute pancreatitis, cholecystitis, bacterial
endocarditis and liver abscess. HAP can be found incidentally but often present with
hemobilia, abdominal pain, jaundice and gastrointestinal bleeding. Radiological imaging
provides the best tool for early diagnosis with selective angiography as the gold
standard for its diagnosis and management possibility. Treatment options for HAP
include surgical repair, endovascular repair including super selective micro-coil
embolization and stent-grafting.

INTRODUCTION

Hepatic artery pseudoaneurysm (HAP) commonly occurs as a post-traumatic

complication after blunt or penetrating injuries and iatrogenic trauma. Non-traumatic
causes are rare and may occur with complications from infections or inflammation
associated with septic emboli. Common presentation includes hemobilia, abdominal
pain, and jaundice. Radiologic imaging provides the best tool for early diagnosis.
Treatment options for HAP include surgical repair and endovascular repair
CASE REPORT

This is an outpatient case of a 43 year old male, who came in to our institution for
a computed tomography study of the whole abdomen. Patient initially sought consult at
a private physician for fever and intermittent epigastric pain, for which a
hepatoprotective agent was prescribed. Four months after, patient had a follow-up
consultation for jaundice, pruritus, new-onset hyperglycemia and hypercholesterolemia.
Oral hypoglycemic agent and anti-cholesterol medications were then prescribed, to
which the jaundice and pruritus were noted to improve. Two months later, patient was
admitted at a Local District Hospital for severe abdominal pain.

Patient works as an electrician, is non-hypertensive and non-diabetic with no

prior history of hospital admission. He has a 17-year history of alcohol intake and a 17
pack-year history of cigarette smoking. History of trauma or any surgical procedure is
negative. There is a known history of bone cancer in the family (brother).

During the period of admission, ultrasound of the whole abdomen was performed
which revealed a complex hepatic mass, probably an abscess formation, and thickened
gallbladder wall with sludge. Whole abdomen triple contrast CT scan study was then
performed which showed hepatomegaly with a suggestive large hepatic
pseudoaneurysm with thrombosis in the left lobe causing minimal mass effect and
partially contracted gallbladder with a non-obstructing distal choledocholithiasis and
surrounding inflammatory changes. Following treatment, patient was discharged well
and improved. However, five days after, patient was again admitted for severe
hematemesis and melena. Radiographic imaging findings are shown below:
Figure1-A.Ultrasoud of the liver shows a complex cystic lesion with internal septations, medium level
echoes and thick echogenic borders in the medial portion of the left lobe, measuring about 5.3 x 5.3 x
4.0 cm (L x W x AP).

Figure1-B.Ultrasoud of the gallbladder shows an un-enlarged gallbladder with thickened walls

and presence of intraluminal medium level echoes.
Figure 2-A. Plain axial CT image shows an enlarged liver with several dystrophic calcifications in
segment II, with slight contracted appearance of said segment. A large, fairly-defined, mildly
lobulated, iso- to hypodense area is identified at segment II-III of the liver, minimally extending to
the caudate lobe.

ARTERIAL PORTAL

Figure 2-B. In the arterial and portal venous phase axial CT images, a well-defined enhancing
(+120 HU) focus is identified at the central aspect of the said area.

Figure 2-C. Delayed phase axial CT image shows a moderate decrease in the density of the
central enhancing region (+63 HU), which is similar to the density of the aorta (white arrow). A
 partly circumferential area of mild hyperdensities (+50 HU) is appreciated surrounding the
enhancing focus. Mass effect is also seen as minimal displacement of the adjacent vascular
structures.

DISCUSSION

Visceral artery aneurysms are rare with an incidence of only 0.01-0.1% of the
population and results from bulging and weakening of the wall of the splenic (most
common), hepatic, renal and mesenteric arteries. It can be true aneurysms or
pseudoaneurysms. True aneurysms are outpouchings containing all three layers of
blood vessel walls (intima, media, and adventitia). Pseudoaneurysms occur when
vessel walls are breached, with blood leaking through the wall but contained by the
adventitia and surrounding soft tissue, causing an outpouching that do not contain at
least one of these layers. Hepatic artery aneurysm (HAA) is the second most common
type of visceral artery aneurysm reported and approximately 50% of HAA are hepatic
artery peudoaneurysm (HAP).

HAP is a potentially life threatening vascular entity and commonly results from
complications of blunt or penetrating trauma and acute or chronic surgical injuries. Non-
traumatic pseudoaneurysm of the hepatic artery is rarely reported, and is usually
caused by arteriosclerosis, polyarteritis nodosa, acute pancreatitis, cholecystitis,
bacterial endocarditis and liver abscess. Upto 60% of HAP are clinically silent and found
incidentally. Symptomatic patients, however, can have non-specific presentation
requiring a high index of suspicion. HAPs often present with hemobilia (90%),
abdominal pain (70%) and jaundice (60%). Less than 40% present with the classic
Quincke's Triad (jaundice, biliary colic, and gastrointestinal bleeding).

HAP rupture is common, occurring in up to 76% of patients and has a high

mortality rate. Early diagnosis and treatment are considered to be essential.
Radiological imaging provides the best tool for early diagnosis of HAP. Selective
angiography is the gold standard in the diagnosis of HAP and at the same time provides
a therapeutic opportunity. CT angiography, MRI angiography and Doppler sonography
offer promising alternatives to conventional angiography for the diagnosis and treatment
planning of HAP.

In the treatment of HAP, surgical reconstruction (resection, revascularization, and

ligation) is typically not the initial recommendation, as it can lead to adhesions and
altered anatomy. Minimally invasive endovascular techniques are both successful and
preferred to prevent these complications. The first-line treatment for HAP is urgent
selective hepatic arterial angiography and embolization. The benefits of angiography
and embolization include speed, targeted therapy, minimal invasiveness, and potential
for repetition, if necessary. A second treatment option is ultrasound-guided
percutaneous thrombin injection, which can decrease the risk of hepatic infarction. This
option has been described in limited case reports and could be considered on a case-
by-case basis.

CONCLUSION

In this patient with no history of trauma, who presented with abdominal pain,
jaundice, gastrointestinal bleeding and medium level echoes within the gallbladder
which could indicate hemobilia, HAP should be suspected. The patient’s CT scan
findings suggestive of a large hepatic pseudoaneurysm should provide strong evidence
for the diagnosis. Since the incidence of HAP rupture is high, prompt work-up should be
advised in such cases to prevent morbidity and mortality-related to rupture and bleeding
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