Cystic artery pseudoaneurysms are rarely seen and can easily be confused with cholelithiasis, as well as missed on imaging. Ultrasound is often performed first, but computed tomography (CT) provides the best characterization. While angiography with staged cholecystectomy is the procedure of choice, upfront surgical intervention can also be safely done. A 52-year-old woman presented with recurrent right upper quadrant pain and nausea and had a CT scan that revealed extensive gallbladder wall thickening with pericholecystic stranding, fluid collections, and an intraluminal hyperdensity that was considered to be cholelithiasis (Fig. 1). On hospital day five, the patient developed worsening symptoms and a repeat CT scan demonstrated an increase in the hyperdense intraluminal focus and hyperdense material in the bile ducts (Fig. 2). Those findings indicated an enlarging pseudoaneurysm with bleeding into the bile ducts. Due to concern for acute bleeding, the patient underwent an exploratory laparotomy. Extensive inflammation was encountered and the pseudoaneurysm was identified and removed (Fig. 3). The bleeding vessel was ligated, and a partial cholecystectomy was performed.

Figure 1.

Initial computed tomography scans. A) Axial and B) coronal views of the pseudoaneurysm identified as a gallstone (red arrows).

Figure 2.

Follow-up computed tomography scans. A) Axial and B) coronal views showing the increased size of the hyperdense intraluminal focus (red arrows) in the region of the gallbladder fossa 5 days after the previous imaging, consistent with pseudoaneurysm.

Figure 3.

Cystic artery pseudoaneurysm resected intraoperatively.