Endoscopic management of obstructive jaundice caused by hemobilia

Dieulafoy lesion of the gallbladder: A rare cause of hemobilia and acute pancreatitis - Case report

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Dieulafoy lesion of the gallbladder is a very rare cause of hemobilia.

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Hemobilia should be considered as a cause of acute pancreatitis.

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Intraoperative cholangiogram is effective in flushing small biliary clots.

Introduction

Dieulafoy lesion of the gallbladder is very rare. It can cause hemobilia and, consequently, acute pancreatitis. After extensive research, the authors found six reported cases of this entity, none of them presenting as acute pancreatitis.

Case presentation

A 78-year-old woman presented to the emergency department a right upper-quadrant pain and nausea. Abdominal ultrasound showed a gallbladder full of a heterogenic content with no signs of lithiasis or acute cholecystitis. Blood lipase was significantly elevated. She was admitted for acute pancreatitis. During hospitalization she developed jaundice and hematemesis requiring blood transfusion. The upper gastrointestinal (GI) endoscopy with side-view duodenoscopy showed blood through the papilla of Vater. Computed tomography and magnetic resonance imaging confirmed the content of the gallbladder with no changes in the biliary tree. A laparoscopic cholecystectomy with intraoperative cholangiogram was performed. Histology revealed a Dieulafoy lesion. The patient was discharged three days after surgery and had no subsequent episodes.

Conclusion

Hemobilia should be considered as a cause of upper GI bleeding and acute pancreatitis, especially if both are concurrent. Treatment is directed to the cause, with bleeding control and restoration of bile flow, which can be accomplished by a single minimally invasive surgery.

Successful disintegration, dissolution and drainage of intracholedochal hematoma by percutaneous transhepatic intervention

Hemobilia is a rare biliary complication of liver transplantation. The predominant cause of hemobilia is iatrogenic, and it is often associated with traumatic operations, such as percutaneous liver intervention, endoscopic retrograde cholangiopancreatography, cholecystectomy, biliary tract surgery, and liver transplantation. Percutaneous transhepatic cholangiography and liver biopsy are two major causes of hemobilia in liver transplant recipients. Hemobilia may also be caused by coagulation defects. It can form intracholedochal hematomas, causing obstructive jaundice. Herein we describe a patient with an intracholedochal hematoma resulting in significant obstructive jaundice after liver transplantation for fulminant hepatic failure. Previous studies have shown that percutaneous transhepatic manipulation is a major cause of hemobilia after liver transplantation, but in our case, percutaneous transhepatic intervention was used to relieve the biliary obstruction and dissolve the biliary clot, with a good outcome.

Etiology, clinical features, and endoscopic management of hemobilia: a retrospective analysis of 37 cases

BACKGROUND/AIMS

Hemobilia is a rare cause of upper gastrointestinal bleeding. Endoscopic retrograde cholangiopancreaticography (ERCP) is considered to be an excellent diagnostic and treatment modality. Thirty-seven cases of hemobilia with different underlying pathologies were analyzed to illustrate clinical features and to evaluate the role of endoscopic management.

METHODS

A total of 37 patients (26 men and 11 women; mean age, 66.2±15.3 years) who were confirmed to have hemobilia by ERCP in a single center from 2000 to 2010 were reviewed retrospectively. Patients with iatrogenic causes of hemobilia were excluded in this study.

RESULTS

The causes of hemobilia were hepatocellular carcinoma in 14, bile duct and gallbladder malignancies in 12, common bile duct stones with cholangitis in 4, acute cholecystitis in 4, and pancreatic cancer in 2 patients. The clinical features of hemobilia were jaundice (89.2%), abdominal pain (78.4%), and melena (13.5%). The cholangiographic findings of hemobilia were amorphous filling defects in 15, tubular filling defects in 6, and cast-like filling defects in 6 patients. Endoscopic management included endoscopic nasobiliary drainage in 26 patients and endoscopic retrograde biliary drainage in 7 patients. Biliary obstruction caused by hemobilia was successfully treated with endoscopic biliary drainages in most cases.

CONCLUSIONS

The most common non-iatrogenic causes of hemobilia were hepatobiliary malignancies, and the majority of patients presented with jaundice and abdominal pain. Endoscopic biliary drainage is recommended as the initial management to control biliary obstruction.

Case report: acute pancreatitis caused by postcholecystectomic hemobilia

Background

Hemobilia is a rare cause of upper GI bleeding and the reasons for the majority of the cases are iatrogenic. It is also one of the rarest vascular complication following laparoscopic cholecystectomy but acute pancreatitis due to postcholecystectomic hemobilia as a late complication of cholecystectomy is not yet described.

Case Presentation

We presented the case of a 32-year-old female, admitted to our emergency surgery clinic with hematemesis, jaundice and abdominal pain who had a history of laparoscopic cholecystectomy 4 months ago. Patient was diagnosed as acute pancreatitis and obstructive jaundice caused by postcholecystectomic hemobilia. Afterwards she is successfully treated by ERCP, angiographic identification and embolization of right hepatic artery pseudoaneurysm.

Conclusions

We presented that postcholecystectomic hemobilia may cause acute pancreatitis and acute pancreatitis caused by postcholecystectomic hemobilia should also be included to the rare complications which may occur following cholecystectomy.

Hemobilia complicating a liver abcess

We present the case of an 11-year-old female, with a history of colicky pain abdomen fever, and episode of massive hematemesis and melena. The child was presented to the medical emergency with features of shock. Coagulation profile of the child was normal. Ultrasonography demonstrated multiple liver abscess. Repeated endoscopies ruled out the possibility of gastric or upper gastrointestinal causes of bleed where in the possibility of hemobilia, was considered. Endoscopic retrograde cholangiography demonstrated the presence of bleeding from the biliary tract. Angiography demonstrated the presence of the communication of the biliary radicles with the hepatic vessels and also aided with therapeutic embolization. Hemobilia is a rare cause of upper gastrointestinal hemorrhage with an increasing incidence because of the widespread use of invasive hepatobiliary procedures and improved recognition. In the majority of cases the cause is iatrogenic and those associated with the liver abscess are scantily reported in the English literature. Persistent bleeding sometimes requires urgent therapeutic intervention, such as angiography or surgery.

Haemobilia

BACKGROUND

This review aims to establish whether increased use of invasive procedures and the trend toward conservative management of major trauma has resulted in an increased incidence of haemobilia.

METHOD

A Medline (http://igm.nlm.nih.gov/)-based search of the English language literature from January 1996 to December 1999 inclusive was performed using the keywords haemobilia, hemobilia, haematobilia and hematobilia. The presentation, aetiology, investigation, management and outcome of 222 cases were reviewed.

RESULTS

Two-thirds of cases were iatrogenic while accidental trauma accounted for 5 per cent. Haemobilia may be major, constituting life-threatening haemorrhage, or minor; it may present many weeks after the initial injury. Diagnosis is most commonly confirmed by angiography. Management is aimed at stopping bleeding and relieving biliary obstruction; 43 per cent of cases were managed conservatively and 36 per cent were managed by transarterial embolization (TAE). Surgery was indicated when laparotomy was performed for other reasons and for failed TAE. The mortality rate was 5 per cent.

CONCLUSIONS

Although the incidence of iatrogenic haemobilia has risen considerably, the bleeding is often minor and can be managed conservatively. When more urgent intervention is required, TAE is usually the treatment of choice. There is no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia.

Hemobilia, a rare cause of acute pancreatitis after percutaneous liver biopsy: diagnosis and treatment by endoscopic retrograde cholangiopancreatography

We here report the case history of a 75-yr-old woman who developed pancreatitis and recurrent symptomatic, cholestasis-induced hemobilia after percutaneous liver biopsy. An endoscopic sphincterotomy with clot extraction led to relief of symptoms. The risk of hemobilia after percutaneous liver biopsy is less than one per 1000 procedures, and only two cases of acute pancreatitis after percutaneous liver biopsy have previously been reported. To our knowledge, this is the first case in which endoscopic retrograde cholangiopancreatography was used to both diagnostic and therapeutic ends.