LAUSR

A 31-year-old male from India presented to the emergency department after developing haematemesis and collapse in the waiting room of his general practitioner. He had presented 2 weeks prior with lethargy, weight loss and bloating. He was normotensive but tachycardic (110 beats/min). He had no abdominal tenderness and no signs of peritonism. His laboratory tests demonstrated obstructive liver function tests and a bilirubin of 153. He proceeded to computed tomography of the abdomen that showed a large hepatic artery pseudoaneurysm causing biliary obstruction, with intrahepatic bile duct dilatation and distension of the gallbladder (Fig. 1). The pseudoaneurysm was deemed too large for interventional radiological techniques, and thus he proceeded to emergency theatre for open repair. En route to theatre, the patient developed severe abdominal pain with a haemoglobin drop to 74 from 129. Intraoperatively, a large right hepatic artery pseudoaneurysm with rupture into the common bile duct was demonstrated, with a gangrenous gallbladder. Resection of the hepatic artery aneurysm required complete exclusion of the right hepatic artery. The bile duct defect was repaired primarily using 5.0 PDS and T-tube coverage with a portion of the aneurysm wall. Intra-abdominal drains were placed around the bile duct. Tubogram (Fig. 2) on day 13 post operation showed unobstructed distal flow in bile duct. He was discharged on day 17 with T-tube in situ and planned reconstruction with a Roux-enY hepaticojejunostomy. Histopathology did not demonstrate a malignant cause for the aneurysm. Rupture of a hepatic arterial aneurysm into the biliary tree is a rare cause of haemobilia. It is most commonly a result of rupture of a pseudoaneurysm that has formed following biliary injury at cholecystectomy, but can also form following major hepatic, biliary or pancreatic operations, following blunt or penetrating trauma, or rarely due to inflammatory processes. Patients with a ruptured hepatic artery aneurysm usually present with right upper quadrant pain and jaundice and haemodynamic instability, or simply can have a transaminitis. Management of hepatic artery aneurysms includes interventional radiological procedures, such as embolization and stenting, as well