A137 AN ELUSIVE GASTROINTESTINAL BLEED: A CASE OF RUPTURED CYSTIC ARTERY PSEUDOANEURYSM WITH PREVIOUS BILLROTH-II SURGERY
Bibliographic record
Abstract
Abstract Background Cystic artery pseudoaneurysm (CAP) is a rare but potentially life-threatening cause of upper gastrointestinal (GI) bleeding and requires urgent intervention. Aims To describe the clinical enigma of CAP in the context of distorted anatomy and discuss management. Methods Case report and review of literature Results Case Report A healthy 91-year-old man with a remote history of gastric ulcer perforation leading to Billroth-II surgery 40 years ago presented to a community hospital with melena. He had no abdominal pain and liver enzymes were normal. His hemoglobin was 97 g/L (from 137 g/L the month prior) with a BUN:Cr ratio of 50.6 mg/dL and white cell count of 14.4 x109/L. Upper endoscopy identified a large adherent clot in the stomach that could not be dislodged and was suspected to obscure the culprit lesion. Afferent and efferent limbs from previous Billroth-II surgery were identified but not intubated. He was managed supportively with acid suppression and blood transfusion, but his hemoglobin continued decreasing, leading to transfer to a tertiary centre. Upon arrival he had new-onset abdominal pain, rigors, and diaphoresis with a heart rate of 175 beats/minute and blood pressure of 75/40 mmHg. After resuscitation, emergent CT angiogram demonstrated acute contrast extravasation into the gallbladder in keeping with a ruptured CAP. He underwent successful coiling of the cystic artery. Following this, his abdominal pain resolved, and hemoglobin stabilized. Repeat endoscopy demonstrated Billroth-II anatomy without bleeding lesion. He was treated with antibiotics for presumed cholecystitis and discharged home for outpatient cholecystectomy. Literature Review CAP is a rare cause of hemobilia, described only in case reports. The complete hemobilia triad of jaundice, right upper quadrant pain, and GI bleeding is absent in the majority of cases, requiring endoscopic evaluation of the ampulla of Vater or contrast CT. The most common causes of CAP are iatrogenic from cholecystectomy, cholecystitis, gallstones, and malignancy. These mechanisms, whether through trauma or inflammation, lead to damage of the gallbladder wall and the cystic artery. Contained CAP can lead to intermittent bleeding whereas ruptured CAP causes brisk arterial bleeding, necessitating arterial embolization or emergent cholecystectomy. In cases of biliary obstruction, either from the original process or subsequent blood clot at the ampulla, ERCP can lead to successful decompression. Conclusions We present a case of ruptured CAP which eluded diagnosis due to diagnostic rarity, lack of clinical clues, and distorted anatomy. CAP should be considered with a history of recent cholecystectomy, acute cholecystitis, or gallstones. Maintaining an index of suspicion for rare causes of GI bleeding can ensure timely diagnosis and escalation to the appropriate level of care. Funding Agencies None
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.004 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.004 | 0.002 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.003 | 0.003 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.005 | 0.003 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".