Hemobilia after percutaneous transhepatic biliary drainage: treatment with transcatheter embolotherapy

Biliary fistulae and haemorrhage

Percutaneous biliary drainage is the most common aetiology of haemobilia. Bile duct fistulae can also arise from the hepatic or portal vein, most commonly as a result of trauma. Percutaneous methods for treating haemobilia from all these sources are discussed in detail.

Use of articulated catheters in the treatment of biliary strictures

We have used a single articulated catheter to obviate the need for multiple catheters in patients with complex biliary strictures or strictures associated with small or immature tracts. Two- and three-arm articulated drains (8-14 Fr) made from segments of biliary catheters were placed in 16 patients. Nine were placed transhepatically, 6 transperitoneally through existing T-tube tracts, and 1 through a cystic duct fistula. Six malignant and 10 benign strictures were stented with various catheter configurations through a single tract. Fifteen patients had two catheter components with one articulation and 1 patient had three catheter components with two articulations. The average duration of catheter drainage was 7.0 +/- 4.2 months. Routine catheter exchanges were performed; two spontaneous occlusions occurred. In patients where internal stenting may be difficult or undesirable, articulated catheters allow satisfactory external and internal drainage of complex benign and malignant strictures through a single tract, avoiding the need for multiple transhepatic catheters.

Management of upper gastrointestinal bleeding in the patient with chronic liver disease

This article reviews the management of severe upper gastrointestinal bleeding in the patient with chronic liver diseases. The initial assessment, diagnostic work-up, and treatment options for variceal and nonvariceal bleeding are discussed. The role of diagnostic and therapeutic endoscopy for esophagogastric varices is reviewed with special emphasis on new endoscopic techniques including variceal band ligation and cyanoacrylate injection. Various pharmacologic, surgical, and radiologic treatment options for variceal bleeding also are discussed. In addition, nonvariceal causes of severe upper gastrointestinal bleeding are reviewed including peptic ulcer diseases, Mallory-Weiss tear, portal hypertensive gastropathy, and gastric antral vascular ectasia.

Superselective arterial embolization in the liver transplant recipient: a safe treatment for hemobilia caused by percutaneous transhepatic biliary drainage

Transcatheter arterial embolization is widely used to treat life-threatening iatrogenic hemobilia, although in the transplanted liver its use has only been reported in two cases. To evaluate more fully whether transcatheter embolization is safe and effective in transplant recipients, we retrospectively reviewed eight cases of severe hemobilia. These occurred after 128 percutaneous transhepatic biliary drainage procedures performed during a 6-year period. In each case, angiography localized the bleeding to a specific intrahepatic branch that was then subselectively catheterized and occluded by transcatheter embolization. Bleeding was successfully controlled by this method in all eight patients with no immediate complications. The main, right, and left hepatic arteries were shown to be patent immediately after embolization by angiography in all patients. Duplex sonography performed in each case (1 to 4 months) after the procedure confirmed that patency was maintained in all patients. No patients developed liver abscesses, sepsis, or clinical liver infarctions after the embolization. No patients underwent retransplantation after embolization. Our experience shows that superselective transcatheter embolization is a safe, effective therapy to correct iatrogenic hemobilia in the liver transplant recipient without threatening the patency of the major hepatic arteries, the viability of the liver, or the integrity of the biliary tree.

Embolization of an hepatic artery pseudoaneurysm following laparoscopic cholecystectomy

Vascular injuries during laparoscopic cholecystectomy can occur in an analogous fashion to biliary injuries, with potential laceration, transection, and occlusion of blood vessels. A patient presented with symptomatic hemobilia 1 month following laparoscopic cholecystectomy and was found to have a right hepatic artery pseudoaneurysm which communicated with the common bile duct. This was successfully embolized with several embolic agents, resulting in rapid resolution of all signs and symptoms. The patient has been free of symptoms during a follow-up period of 1 year. A brief discussion of hepatic artery pseudoaneurysms is presented.

Treatment of hemobilia with selective hepatic artery embolization

PURPOSE

To evaluate retrospectively the results of selective transcatheter embolization in the treatment of hemobilia.

PATIENTS AND METHODS

Twelve patients with hemobilia (mean age, 43 years) underwent embolotherapy. Causes of hepatic vascular injury were iatrogenic trauma, blunt external trauma, septic emboli, and lupus vasculitis. A 5-F cobra catheter or a 5-F non-tapered Simmons shaped catheter passed over a hydrophilic guide wire, or a Tracker 18 catheter forming a coaxial system was used. Embolic agents included gelatin sponge or polyvinyl alcohol fragments used alone or with coils.

RESULTS

Hepatic artery pseudoaneurysms were found in 10 patients, ruptured hepatic artery aneurysm was found in one, and arterioportal fistula was found in two (with pseudoaneurysm in one). Bleeding was immediately controlled in 11 of 12 patients after embolization; one patient rebled and underwent surgery. Two patients underwent repeat embolization (2 weeks and 2 months later). Two patients died, one of biliary sepsis and liver insufficiency 24 hours after embolization and the other of gangrenous cholecystitis.

CONCLUSION

Transcatheter embolization is an effective treatment of hemobilia. It allows control of bleeding and identification of the origin of the hemorrhage.

Catheter tract hemorrhage during percutaneous biliary intervention: management with use of a retained transhepatic guide wire

PURPOSE

The authors present their experience in managing freely flowing hemorrhage from immature catheter tracts in patients undergoing biliary drainage.

PATIENTS AND METHODS

Transhepatic guide wires were maintained securely whenever catheters were removed from the liver. Six patients among 71 hemorrhaged profusely when drains were manipulated within 4 days of initial catheterization. Management was attempted with use of the transhepatic guide wires.

RESULTS

Maneuvers performed over the retained guide wire controlled bleeding in all six patients. Reintubation constituted definitive therapy in five patients. A biliary-portal venous fistula in the remaining patient was treated with thrombin. The retained guide wire proved necessary in all cases.

CONCLUSION

Hemorrhage from immature catheter tracts can be managed, often definitively, with maneuvers performed over a retained transhepatic guide wire. Accordingly, a secure transhepatic guide wire is essential prior to removal of hepatic catheters and should remain in place until the absence of bleeding is established. These maneuvers may become increasingly important as courses of biliary catheterization become shorter.