Pseudoaneurysm of any artery develops due to collection of blood between its two outer layers, the tunica media and the tunica adventitia. It is in contrast with the true aneurysm which involves all three layers of the wall of an artery. Among children sustaining traumatic injuries, 21% have abdominal injuries [1,2]. Rarely, the blunt trauma of the abdomen may be complicated by develop-ment of pseudoaneurysm of hepatic artery, which may rupture inside biliary tract, leading to life-threatening complication of hemobilia. Classical signs of hemobilia consist of upper abdominal pain, upper gastrointestinal hemorrhage and jaundice, called Quincke triad. All these three signs are present in only 22% of cases, whereas only upper gastrointestinal bleeding is present in 42% of cases [3].

An 8-year-old child presented in our emergency department with complaint of pain abdomen for 15 days and hematemesis and melena for 10 days. The pain abdomen started when he was punched in his abdomen by one of his schoolmates. He took analgesics for his pain abdomen. There was no history of fever, rash or any bleeding diathesis. He was pale and had tachycardia at admission. There was no history of fever, rashes or any bleeding diathesis. Blood pressure was 113/70 mmHg and there was no petechial/purpuric rash. He was given normal saline bolus and intravenous pantoprazole followed by whole blood transfusion. Blood investigations revealed low hemoglobin (4.8 g/100 mL) with normal leucocyte counts, liver enzymes and renal function tests; International normalized ratio was 0.95. Ultrasonography abdomen done outside had revealed a 9 mm calculus in gall bladder neck. Upper gastrointestinal endoscopy, which had been done prior to coming to our hospital, had documented erosion of mucosa of antrum and pylorus with blood and blood clot inside stomach. Blood was also seen coming out from ampulla of Vater and an impression of erosive gastritis and hemobilia had been reported. The child continued to have hematemesis after admission. A computed tomography (CT) angiography of the abdomen was done which revealed a pseudoaneurysm of the right hepatic artery (Fig. 1a). Percutaneous coil occlusion of the right hepatic artery was done through the ipsilateral femoral artery (Fig. 1b), and the hematemesis stopped thereafter. He continued to have intermittent colicky pain abdomen post procedure also, which persisted along with melena, till sixth day of admission. The child became completely asymptomatic on seventh day of admission, when he was discharged. He was asymptomatic, without any pallor, and with normal liver function test on follow up after one month.

(a)	(b)
Fig. 1 (a) Pseudoaneurysm of right hepatic artery in CT-angiography (arrow), (b) Coil embolization of the pseudoaneurysm of right hepatic artery.

Approximately 1.7% of children sustaining blunt trauma to the abdomen develop pseudoaneurysm of hepatic artery and most of the pseudoaneurysm of the hepatic artery are associated with the higher grades of liver injury [4]. Other causes of pseudoaneurysm of hepatic artery include surgical procedures like cholecystectomy or percutaneous procedures and endoscopic procedures like cholangiopancreatography, liver biopsy and drainage of liver abscess [5]. Pseudoaneurysm may produce mass symptoms and local pain or the situation may be further complicated by rupture of the pseudoaneurysm. Rupture of the pseudoaneurysm occurs within days to weeks after the injury. When the pseudoaneurysm ruptures inside the biliary system, it leads to haemobilia and life threatening upper gastrointestinal bleeding. Ultrasonography may demonstrate pseudoaneurysm as a sac like structure with blood flow within it, but its sensitivity is low (37%) although it has a high specificity (100%). Contrast enhanced ultrasonography has been shown to have high sensitivity (75%) and specificity (100%) [6]. Endoscopy may also detect hemobilia resulting from rupture of pseudoaneurysm by demonstrating blood coming out from papilla of vater, but it also carries a low sensitivity. CT angiography is investigation of choice for pseudoaneurysm of hepatic artery. It provides a precise location of the pseudoaneurysm and delineates the involved blood vessel.

Percutaneous arterial embolization is highly effective in controlling arterial bleeding in hemobilia [7]. Success of endovascular management at experienced centres approaches 100% [8]. In a series of 176 children sustaining liver injury, 3 (1.7%) had developed pseudoaneurysm of hepatic artery [4]. Two of them experienced life-threatening bleeding, both at 10 days after injury. This was controlled by angiographic embolization in one and by laparotomy in other. One asymptomatic patient underwent successful embolization of a large pseudoaneurysm, seven days after injury [4]. Hepatic necrosis, gall bladder ischemia, biliary fistula and hepatic abscess are known complications of this procedure. Surgical intervention is rarely necessary, and it is usually reserved for failed percutaneous embolization. However, it is first line of management if pseudoaneurysm is infected or if it is compressing other vascular structures. On follow-up of such children with coil embolization of hepatic artery, clinical jaundice and liver function test derangement should be looked for.

In conclusion, an upper gastrointestinal bleeding associated with abdominal trauma could be due to hemobilia due to ruptured pseudoaneurysm of hepatic artery. It may lead to life threatening hematemesis, hence prompt recognition of this condition by CT angiography and its management is important.

Contributors: AP: drafted the manuscript, collected clinical details; SK: was involved in doing percutaneous coil occlusion of pseudoaneurysm of the patient in case report; Abhiranjan P: did the literature search related to the topic; PK: reviewed the article and suggested editing. All authors reviewed article before final submission.

Funding: None; Competing interest: None stated.


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