A 42-years-old Caucasian male, without relevant past medical history, was diagnosed with B-cell acute lymphoblastic leukemia. He completed the induction phase of the PETHEMA LAL Ph-2008 protocol, without complications. Later, the patient was readmitted to start the consolidation phase. However, it was noticed new-onset cytocholestasis and hyperbilirubinemia, without coagulopathy or encephalopathy. He had no personal or family history of liver disease. The metabolic, virological and autoimmune study was negative. Abdominal computed tomography scan revealed a liver with normal morphology and without hepatic metastasis or portal thrombosis. Magnetic resonance cholangiopancreatography showed normal intrahepatic and extrahepatic bile ducts. Endoscopic ultrasound (EUS) revealed no focal liver lesions. EUS-guided fine needle biopsy using a 22G needle was performed (2 passes; 22G Acquire, Boston Scientific) obtaining material that was sent for evaluation. The histological examination showed marked canalicular and hepatocytic cholestasis and ductopenia probably due to hepatic drug toxicity.
Ten days after the liver biopsy, the patient presented sudden epigastric pain. He was hemodynamically stable. The abdomen was soft, with epigastric tenderness, without rebound tenderness. Hemoglobin and hepatic profile remained stable and there was no elevation of inflammatory markers. The abdominal ultrasound (US) revealed a heterogeneous lesion with 56 mm located in segment VIII of the liver (Fig. 1).
The abdominal computed tomography scan revealed a hepatic pseudoaneurysm and an adjacent intrahepatic hematoma (Fig. 2).
After the diagnosis, the patient underwent a transcatheter arterial embolization. Complete embolization of pseudoaneurysm was accomplished after 3 embolization sessions, performed during 1 week. During hospitalization, the patient maintained hemodynamic stability, without the need for vasopressor support. The abdominal US showed a dimensional reduction of the pseudoaneurysm, with no evidence of active hemorrhage (Fig. 3). Currently, the patient is followed up in a Gastroenterology consultation and remains well after 5 months of liver biopsy.
A hepatic pseudoaneurysm is a false aneurysm that develops from leakage of an injured artery into the surrounding tissues forming a cavity outside the artery . The development of a hepatic pseudoaneurysm is mainly described in patients after liver trauma but is also reported after invasive procedures such as percutaneous liver biopsies . To our knowledge, hepatic pseudoaneurysm after EUS-guided liver biopsy has yet to be reported. However, pseudoaneurysm after EUS-guided fine needle biopsy from other organs, such as the pancreas, are described in the literature .
Symptoms of a hepatic pseudoaneurysm may vary from clinically silent to signs of rupture with intraperitoneal hemorrhage, rupture into the gastrointestinal tract, venous, portal or biliary system . The diagnosis of a hepatic pseudoaneurysm is made with either arteriography, contrast-enhanced computer tomography or Doppler Ultrasound . The most important differential diagnosis is a parenchymal hematoma. However, hepatic pseudoaneurysm can be distinguished from a hematoma as it continues to communicate with the artery .
All pseudoaneurysms require early treatment to prevent lethal adverse events. Angiography with transcatheter embolization is the initial treatment choice . Several cases in the literature also describe the use of endoscopic ultrasound-guided coiling as a potential alternative to transcatheter embolization . Surgery is indicated for hemodynamic instability, and uncontrolled hemorrhage after angiographic embolization .
Isabel Garrido1, Joel Ferreira Silva1, Rosa Coelho1, Susana Lopes1, Guilherme Macedo1.