Inflammatory and noninflammatory vascular disease causing hemobilia

Area of Science:

• Vascular Medicine
• Gastroenterology
• Diagnostic Imaging

Background:

• Polyarteritis nodosa (PAN) is a systemic vasculitis often diagnosed via characteristic angiographic findings of small- to medium-sized artery aneurysms.
• Vasculitis mimics can present with overlapping clinical and angiographic features, posing diagnostic challenges, particularly in gastrointestinal presentations.
• Hemobilia, or bleeding into the biliary tree, is a rare but serious condition that can be associated with vascular abnormalities.

Observation:

• Two cases of hemobilia are presented, highlighting diagnostic complexities in patients with hepatic artery aneurysms.
• The first patient, an 18-year-old male, presented with epigastric pain and hemobilia due to hepatic artery aneurysms, later confirmed as PAN post-cholecystectomy.
• The second patient, an 18-year-old female, initially showed hepatic artery microaneurysms without bleeding, later developing a hepatic artery-bile duct fistula, ultimately diagnosed with fibromuscular dysplasia after gallbladder hemorrhage.

Findings:

• Angiography revealed multiple hepatic artery aneurysms in the first patient, consistent with PAN.
• The second patient's presentation included microaneurysms and a fistula, with fibromuscular dysplasia identified as the underlying cause.
• Pathologic examination of gallbladder specimens was crucial for definitive diagnosis in both cases.

Implications:

• Clinicians must consider non-vasculitic mimics when evaluating patients with suspected gastrointestinal vasculitis and hepatic artery aneurysms.
• Accurate differentiation between PAN and its mimics is essential for appropriate treatment and patient management.
• This case series underscores the importance of comprehensive diagnostic workup, including pathology, for complex vascular presentations in the hepatobiliary system.