P144 Hepatic artery pseudoaneurysm with recurrent episodes of endoscopically unlocalised upper gastrointestinal bleeding. A rare case report

<h3>Introduction</h3> Hepatic Artery Pseudoaneurysms (HAPs) develop from damage to the arterial wall, resulting in a rupture and the formation of a sac lined by surrounding tissues and organs. HAPs often arise after liver trauma, hepatobiliary surgery, or invasive procedures like percutaneous liver biopsies or cholecystectomies1. It can also occur because of surrounding infection or inflammation in the gallbladder or pancreas 2.Hepatic artery pseudoaneurysm rupture is a rare cause of haemobilia accounting for less than 6% of UGIB 3. Despite its rarity, bleeding from a HAP is potentially life-threatening and requires prompt diagnosis and intervention, We present a case with diagnostic challenges of significant haemobilia caused by HAP. <h3>Case Presentation</h3> An 84-year-old female was admitted with a 2-month history of intermittent upper abdominal pain accompanied by melena. On admission, the patient was hemodynamically stable with mild right hypochondrial tenderness. The results of laboratory tests indicated reduced Hb (93 g/l), abnormal liver function with albumin (28g/L), ALT (459 U/L) (normal range 10- 40), ALP (374 U/L)(normal range 30–130), and total bilirubin (66 umol/l) (normal&lt;21). The patient had attended the hospital twice before and was investigated for possible upper GI bleeding, being discharged home after normal OGD and stable Hb. Past medical history includes mitral valve replacement ,PPM, AF, endocarditis, and CKD stage 3. On the day of admission, the patient was treated conservatively with intravenous fluids and PPI. However, during admission, she developed hematemesis and melena, with hemodynamic compromise and Hb falling to 68 g/l (down from 93 g/l) . An OGD failed to demonstrate a source of bleeding. An ultrasound of the gallbladder and biliary tree was inconclusive for ongoing abdominal pain and abnormal LFTs. A liver CT scan revealed a right hepatic lobe pseudoaneurysm with haemobilia (figure 1). The patient was treated with super selective angioembolization of the branch of the right hepatic artery pseudoaneurysm. After the procedure, the patient showed clinical improvement and maintained a stable hemoglobin level and normal liver function tests. <h3>Discussion</h3> Haemobilia, or bleeding from the hepatobiliary tract, is a rare cause of acute UGI bleeding. It should be considered in any patient with acute UGI bleeding and a recent history of hepatic parenchymal or biliary tract instrumentation and/or injury. In our patient , the etiology of HAP was not identified. Hence, the importance of maintaining a high index of clinical suspicion in patients with normal OGD UGIB . <h3>References</h3> Finley DS, Hinojosa MW, Paya M, Imagawa DK. Hepatic artery pseudoaneurysm: a report of seven cases and a review of the literature. <i>Surg Today</i> 2005;35(7):543–547. Kang M, Bapuraj JR, Khandelwal N, Kochhar R, Kalra N, Verma GR. Liver abscess associated with hepatic artery pseudoaneurysm with arteriovenous fistula: imaging and interventional management. <i>Acta Radiol.</i> Mar 2006;47(2):162–166. Dallal HJ, Palmer KR. Upper gastrointestinal haemorrhage. <i>BMJ</i> 2001;323(7321):1115–1117.