A 49-year-old male underwent open cholecystectomy for acute calculous cholecystitis 8 years back. Intraoperatively, there were dense adhesions in Calot's triangle. Bile duct injury was detected and managed with T-tube placement. He was then referred to our center where he was continued on T-tube drainage and managed conservatively. T-tube was removed after 33 days, and he was kept under regular follow-up. His follow-up investigation report revealed a total bilirubin (TB) 337 umol/L, direct bilirubin (DB) 250 umol/L, serum glutamic oxaloacetate transaminase (SGOT) 56 U/L, serum glutamic pyruvic transaminase (SGPT) 65 U/L, and serum alkaline phosphatase (SAP) 1050 U/L, showing a cholestatic pattern. He was then planned for magnetic resonance cholangiopancreatography (MRCP) which revealed Bismuth type II stricture (Figure 1). For this, he was managed with PTBD and was planned for a definitive procedure. During his follow-ups, his bilirubin level gradually decreased. He underwent hepaticojejunostomy for biliary stricture after 5 months of his initial surgery, and his postoperative period was uneventful and was discharged on 5th postoperative day.
He was on regular follow-up, and his liver function test came to normal (TB: 10 umol/L; DB: 2 umol/L; SGOT: 37 U/L; SGPT: 37 U/L; and SAP: 173 U/L). But after 9 months postoperatively, bilirubin level began to increase gradually. His investigations revealed TB 198 umol/L, DB 164 umol/L, SGOT 46 U/L, SGPT 33 U/L, and SAP 1176 U/L, and ultrasonography reported dilated intrahepatic bile ducts (IHBDs). He then underwent PTBD insertion for suspected HJ stricture (2013 March 03). However, his bilirubin level did not fall as expected, so he underwent re-positioning of the PTBD tube. Two weeks after this procedure, he presented with complaints of easy fatigability and passage of black tarry stool. His investigation revealed hemoglobin 7.4 gm/dl, platelet count 223000/uL PT/INR: 15 sec/1.07, TB 345 umol/L, DB 234 umol/L, SGOT 37 U/L, SGPT 22 U/L, and SAP 519 U/L. CT angiogram was performed to localize the source of bleeding, finding of which showed pseudoaneurysm of segment III hepatic artery of left lobe of liver (Figure 2).
With the diagnosis of hemobilia due to segment III hepatic artery (HA) pseudoaneurysm which likely occurred during PTBD manipulation, selective transarterial coil embolization was done, after which he improved symptomatically and his Hb normalized. He was continued on PTBD through which HJ stricture was dilated gradually with balloon catheters of size ranging from 6Fr to 12Fr. Following adequate dilation, his PTBD tube was removed. Since then, he has been under regular follow-up.