Complications of angiographic embolization for traumatic hemobilia

Haemobilia after penetrating and blunt liver injury: treatment with selective hepatic artery embolisation

Although traumatic haemobilia is uncommon and occurs in less than 3% of liver injuries, the magnitude of the bleeding may result in life-threatening complications. This study evaluated the efficacy of selective hepatic artery embolisation (HAE) in the control of bleeding in patients with traumatic haemobilia. The demographic, clinical and angiographic data on all patients with traumatic haemobilia were obtained from a prospectively documented database of patients undergoing visceral angiography for liver haemorrhage between 1967 and 2002. During the 36-year period under review, 30 patients were found to have haemobilia on selective hepatic angiography. Ten of these 30 patients had haemobilia due to accidental non-iatrogenic trauma and form the basis of this study. In 8 of the 10 patients haemobilia resulted from penetrating liver injuries and two patients had blunt trauma. The mean delay between the initial injury and the diagnosis of haemobilia was 23.5 (range 1-120) days. The mean blood loss before angiography was 8 (range 3-19) units. Six patients were treated successfully with selective hepatic arterial embolisation, three required surgery and one resolved without any intervention. There were no deaths and no complications resulting in long term sequelae. Traumatic haemobilia is an uncommon but life-threatening complication of liver injury. Selective arterial embolisation is the initial treatment of choice with a substantial rate of success and a low incidence of serious complications.

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.