From Hemobilia to Hematochezia

•A 49-year-old woman

•transferred from an outside hospital because of severe hematochezia with a drop in hemoglobin from 14 to 8.3 g/dl.

• She initially presented because of a sudden onset of intense and constant sharp pain in the epigastric area that started soon after food intake.

• Two months prior to her hospitalization she underwent a laparoscopic cholecystectomy for recurrent abdominal pain.

• Her surgery and initial recovery was uneventful

• although she occasionally experienced brief episodes of epigastric pain that were less intense and never lasted longer than 30 min.

prior medical history

• Her prior medical history was otherwise only remarkable for a quiescent ulcerative colitis.

physical examination

• The main findings on physical examination were icteric sclerae

• and mild skin icterus

• as well as dark blood in the rectal ampulla.

laboratory tests

• demonstrated a moderate elevation of her bilirubin with 4.7 mg/dl (direct bilirubin: 4.5 mg/dl)

• liver enzymes with alkaline phosphatase of 127 U/l,

• AST 197 U/l

• ALT 469 U/l.

ultrasound examination

To further delineate the underlying problem an ultrasound examination was performed

• which demonstrated a fluid collection in the gallbladder fossa

• and a dilation of the intra- and extrahepatic biliary tree .

endoscopy

• An initial endoscopy with antegrade scope did not reveal a bleeding site in the proximal GI tract.

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side-viewing endoscope

a prominent papilla was seen with the side-viewing endoscope.

• Upon intubation of the papilla, a significant amount of blood drained from the bile duct .

• Contrast injection into the common bile duct demonstrated blood clots .

angiogram

• An angiogram showed a large aneurysm of the right hepatic artery with penetration and bleeding into the biliary tree .

Diagnosis

• The combination of abdominal pain, bleeding and icterus after cholecystectomy pointed at problems in the biliary tree.

• Based on these findings, the patient underwent embolization of the feeding artery, which achieved hemostasis .

Discussion:

Hemobilia is defined as blood in the biliary tree

• which can manifest as melena,

• hematochezia,

• and hematemesis or as a gradual blood loss associated with biliary colic and/or jaundice.

• Only about 5 % of the patients with hemobilia present with all three signs and symptoms.

Etiology

• Etiology may be trauma,

• most often iatrogenic (50% in Western countries),

• infection (more common in 3rd World),

• malignancy,

• chronic inflammatory disorders, or gallstones.

• The combination of acute biliary symptoms, jaundice and gastrointestinal bleeding should raise the suspicion for hemobilia,

• especially if the patient had recently undergone a liver biopsy (typically less than 5 days prior to presentation), a cholecystectomy or any surgical or endoscopic manipulations of the biliary system (up to 3-5 weeks prior to presentation).

• The diagnosis of hemobilia can be made endoscopically when bleeding from the ampulla is seen.

• Ultrasound and /or CAT scan may show intrahepatic fluid collections and / or ductal dilation.

• Scintigraphy with labeled erythrocytes may suggest hemobilia and trigger the next step,

• angiography that typically is diagnostic.

treatment

• In the past, treatment for hemobilia has mostly been surgical, frequently requiring a partial hepatectomy if the liver is source of bleeding.

• Alternatively, hepatic ligation has been performed successfully. Based on the results of hepatic artery ligation, angiographic embolization has been tried with success rates exceeding 80 %, making it the initial treatment of choice in most patients.