SciELO - Scientific Electronic Library Online

vol.109 issue8Efficacy of peroral endoscopic myotomy compared with other invasive treatment options for the different esophageal motor disordersAdult gastric duplication: una entidad desconocida dentro del espectro de lesiones submucosas gástricas author indexsubject indexarticles search
Home Pagealphabetic serial listing  


Services on Demand




Related links

  • On index processCited by Google
  • Have no similar articlesSimilars in SciELO
  • On index processSimilars in Google


Revista Española de Enfermedades Digestivas

Print version ISSN 1130-0108

Rev. esp. enferm. dig. vol.109 n.8 Madrid Aug. 2017




Hemobilia due to a cystic artery pseudoaneurysm on ultrasound

Hemobilia por pseudoaneurisma de la arteria cística en ecografía



Victoria de-Lara-Bendahán1, Encarna García-Domínguez2, Marta Rivas-Rivas2 and Jesús García-Serrano1

Clinical Management Unit of 1Radiodiagnosis and 2Digestive Diseases. Hospital Universitario de Puerto Real. Cádiz, Spain



Case report

An 85-year-old woman with a history of gallbladder stones presented with epigastric pain and vomiting. Blood chemistry showed: GGT 350, AP 215, bilirubin 3.4 (direct 2.6) and CRP 2.11. Ultrasound revealed a thickened gallbladder with a stone, echogenic bile and a 3-cm intravesical collection around the calculus (Fig. 1). Doppler examination showed bidirectional vascular flow expressed as two different colors within the intravesical collection (Fig. 2).




Later she presented with melena, which prompted an endoscopic retrograde cholangiography procedure that resulted in bleeding and clot removal. An angio-CT scan was performed due to the suspicion of hemobilia due to a pseudoaneurysm complicating calculus cholecystitis. The scan showed a dilated cystic artery with a pseudoaneurysm (Fig. 3). The laparoscopic cholecystectomy specimen had a recent bleeding site.




Cystic artery pseudoaneurysm is a rare, usually iatrogenic cause of hemobilia (1), although cases secondary to cholecystitis have been reported (2). Arterial wall erosion from inflammation may cause its development (2).

Ultrasound may identify the focally dilated artery as a collection within the gallbladder (3). Doppler ultrasound revealed bidirectional vascular flow which is a mix of two colors due to the turbulent flow inside the pseudoaneurysm. This is known as the "yin-yang sign" due to its similarity with the Asian symbol (3). CT angiography or arteriography demonstrated the focally dilated artery (1). However, doppler ultrasound was the most useful study to confirm the suspicion in a rapid, effective, non-invasive manner in our case.



1. Asad Ali, Sofronis Loizides, Richard Newton, et al. Laparoscopic management of a cystic artery pseudoaneurysm in a patient with calculus cholecystitis. Int J Surg Case Rep 2015;14:182-5. DOI: 10.1016/j.ijscr.2015.08.007.         [ Links ]

2. De Quinta Frutos R, Moles Morenilla L, Docobo Durantes F, et al. Hemobilia secondary to chronic cholecystitis. Rev Esp Enferm Dig 2004;96:221-5. DOI: 10.4321/S1130-01082004000300009.         [ Links ]

3. Badano F. Signo del Yin-Yang. Rev Arg Radiol 2010;74:403-5.         [ Links ]