A rare incidence of a hepatic artery pseudoaneurysm following plastic biliary stent insertion

Hepatic artery pseudoaneurysms have been reported to occur in approximately 1% of cases after metal stenting for malignant biliary obstruction. In contrast, only a few cases have been reported as complications after plastic stenting for benign biliary disease. We report a 61-year-old man with cholangitis who presented with a rare complication of hemobilia after implantation of 7 Fr double pigtail plastic biliary stents. No bleeding was observed approximately one month after biliary stent tube removal. Contrast-enhanced CT scan revealed a circularly enhanced lesion (5 mm in diameter) in the arterial phase at the tip of the previously inserted plastic bile duct stent. Color Doppler ultrasonography enhanced the lesion and detected arterial blood flow inside. He was diagnosed with a hepatic artery pseudoaneurysm. However, he had no risk factors such as prolonged catheterization, severe cholangitis, liver abscess, or long-term steroid use. Superselective transarterial embolization using two metal microcoils was successfully completed without damage to the surrounding liver parenchyma. If hemobilia is suspected after insertion of a plastic bile duct stent, immediate monitoring using contrast-enhanced computed tomography or Doppler ultrasonography is recommended.

Delayed Post-Traumatic Hemobilia in a Patient With Blunt Abdominal Trauma: A Case Report and Review of the Literature

Hemobilia is a rare condition defined as bleeding in the biliary tract. The clinical presentation is variable. The typical manifestation consists of jaundice, upper gastrointestinal bleeding, and right upper quadrant abdominal pain. This set of symptoms is known as "Quincke's triad." It is present in only 22%-35% of cases. Post-traumatic hemobilia is an extraordinarily rare condition occurring in only 6% of the patients with hemobilia. In general, it occurs in less than 0.2% of patients with liver trauma. A delay in the development of bleeding after liver trauma is frequent. Early diagnosis is essential because massive bleeding into the biliary tract is a potentially life-threatening condition. We present a case of a patient with massive hemobilia developed 12 days after blunt abdominal trauma. Computed tomography angiography showed two pseudoaneurysms in hepatic segments V and VIII with contrast medium extravasation. We successfully performed digital subtraction angiography with selective transcatheter arterial embolization of the leaking segment VIII pseudoaneurysm. Embolization of the pseudoaneurysm in segment V was technically impracticable. Our article provides a review of the published literature focussing on the prevalence, diagnostics, and treatment of post-traumatic hemobilia.

Late-onset hemobilia due to pseudoaneurysm rupture after endoscopic ultrasound-guided hepaticogastrostomy

We report the case of a 65-year-old man who experienced hemobilia due to rupture of a pseudoaneurysm of the left hepatic artery after endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS). The patient was diagnosed with pancreatic cancer and underwent endoscopic retrograde cholangiopancreatography for obstructive jaundice. Biliary drainage was converted to EUS-HGS due to tumor invasion in the superior duodenal angle. A partially covered metal stent was placed in the B3 intrahepatic bile duct. The procedure was completed without early complications, but 50 days later, the patient developed fever, elevated hepatobiliary enzymes, and shock. Contrast-enhanced computed tomography (CT) showed that the hepatic end of the HGS stent had moved slightly toward the stomach compared to the previous CT. A 6-mm pseudoaneurysm was also observed near the A3 and A4 branches of the left hepatic artery, coinciding with the hepatic end of the EUS-HGS stent. Hemostasis was achieved with coil embolization. Biliary hemorrhage due to rupture of a pseudoaneurysm should be considered in the differential diagnosis of biliary obstruction accompanied by bleeding after EUS-HGS.

Hemobilia due to porto-biliary fistula complicating endoscopic retrograde cholangiopancreatography after a recent liver transplantation

A 60-year-old woman with autoimmune hepatitis submitted to liver transplantation presented with a biliary anastomotic stenosis. An endoscopic retrograde cholangiopancreatography (ERCP) was complicated with a porto-biliary fistula due to the misplacement of a biliary stent. After multidisciplinary discussion, and the stent was endoscopically removed while a percutaneous transhepatic fully-covered self-expanded metal stent was placed in portal vein. Iatrogenic porto-biliary fistula following biliary stent placement is a rare and potentially life-threatening ERCP complication. In a suspected stent-related portal vein injury, this multidisciplinary strategy combining gastroenterology and radiology proved to be an effective and safe minimally invasive technique avoiding catastrophic consequences.

Rare cause of obstructive haemobilia with recurrent biliopancreatic complications: a paradigmatic case

Haemobilia is an unusual but significant cause of upper gastrointestinal bleeding. Two-thirds of haemobilia cases are secondary to invasive hepato-biliopancreatic procedures. Biliary angiodysplasia is exceptionally unusual, with only three cases reported. Herein, we report the case of an autonomous 80-year-old woman with a history of cholecystectomy 5 years ago and cardiovascular disease-hypertension, heart failure, acute myocardial infarction, stroke and non-valvular atrial fibrillation, anticoagulated with apixaban 2.5 mg two times per day. Since July 2019, she had four episodes of acute cholangitis of mild-to-moderate severity, having undergone broad spectrum antibiotics treatment and endoscopic retrograde cholangiopancreatography (ERCP), with sphincterotomy and bile sludge extraction. After 3 months, the patient presented with a new episode of acute cholangitis, this time with haemobilia (Quincke's triad). An abdominal CT angiography showed no evidence of active bleeding, with plastic biliary prosthesis left by ERCP. The patient continued presenting new episodes of acute cholangitis with haemobilia, some of them with associated pancreatitis. A cholangioscopy with Spyglass DS II was performed, showing an angiodysplasia occupying half of the luminal circumference of the middle choledoccus, without active haemorrhage. After a multidisciplinary meeting and given the high haemorrhagic/thrombotic risk (CHA2DS2-VASc 8), closure of the left atrial appendage was considered. However, relapse of the condition after beginning the antiaggregation protocol for cardiovascular intervention made it unfeasible. Another cholangioscopy with an ultra-thin endoscope for argon-plasma coagulation was attempted, without success. The abdominal CT angiography was repeated, this time with identification of dilated ramifications of the gastroduodenal and inferior pancreatic arteries. After embolisation of these aberrant vessels with microcoils, the patient went well, with no recurrence of bleeding or biliopancreatic complications. We present a case of obstructive haemobilia with multiple biliopancreatic complications, secondary to an extremely rare cause-choledochal angiodysplasia. Cholangioscopy had a decisive role in the diagnosis and therapeutic guidance. The diagnostic/therapeutic challenge associated with haemobilia stands out, with the need for a personalised and multidisciplinary approach.

Coils migrate into the biliary-jejunum anastomosis: A case report

RATIONALE

Coils migration following endovascular treatment of arterial bleeding is rare. There was no clear route to deal with this complication.

PATIENT CONCERNS

A 55-year-old woman underwent choledochal cyst excision with hepaticojejunostomy. At the 18th day after operation, intra-abdominal hemorrhage occurred. Angiography showed active bleeding of 1 branch of the right hepatic artery and the gastroduodenal artery. That was treated by micro-coils embolization. 122 days after embolization, the patient was readmitted for chills, fever with temperature of 40°C, and jaundice.

DIAGNOSIS

Obstructive cholangitis.

INTERVENTIONS

Endoscopy was performed, which showed the micro-coils were embedded in biliary-jejunum anastomosis. Biliary sludges were adherent around micro-coils that were considered the cause of obstructive jaundice, which were washed by endoscopy.

OUTCOMES

Two days later endoscopy therapy, the total bilirubin (TBIL) was decreased to 58.7 μmol/L, and the patient was discharged. After 2 months of follow-up, the level of TBIL was in normal range.

LESSONS

Coils migration following endovascular treatment of arterial bleeding is rare. For cases with coils migrated into the biliary tract, further treatment is often needed because of the secondary cholangitis or stones. Endoscopy might be useful to deal with this intractable problem.

Hepatic artery embolization cures the acute pancreatitis associated with a tiny arteriobiliary fistula after TIPS: A case report

RATIONALE

Esophageal variceal bleeding caused by portal hypertension is massive and life-threatening to those patients with decompensated liver cirrhosis. A transjugular intrahepatic portosystemic shunt (TIPS) can effectively stop bleeding. But the process of puncture may lead to bile duct injury and even form fistulas between the hepatic artery and bile duct.

PATIENT CONCERNS

The case report illustrated a 52-year-old Chinese female patient who underwent TIPS.

DIAGNOSES

She suffered from acute upper gastrointestinal hemorrhage and acute pancreatitis because of the bile duct injury after TIPS.

INTERVENTIONS

The fistulas between the hepatic artery and bile duct was embolized.

OUTCOMES

The acute upper gastrointestinal hemorrhage and acute pancreatitis of the patient were cured.

LESSONS

The arteriobiliary fistula should be paid more attention after TIPS while early-stage prevention should be carried out.

Life threatening hemobilia after endoscopic retrograde cholangiopancreatography (ERCP)

Arterial vascular complication from endoscopic retrograde cholangiopancreatography (ERCP) is exceedingly rare. This report describes a life threatening hemobilia, from a pseudoaneurysm of the right hepatic artery (RHA), which occurred post ERCP. The pseudoaneurysm and the active bleed were diagnosed by selective angiography of the RHA, and successfully treated with stenting.

Haemobilia - A Rare Cause of Upper Gastro-Intestinal Bleeding

Haemobilia is a rare cause of upper gastrointestinal bleeding that consists of haemorrhage within the biliary tree. Most cases of haemobilia are due to iatrogenic cause, laparoscopic or open cholecystectomy, abdominal trauma, gallstones, hepatic tumours, vascular aneurism. We present the case of a male patient admitted in the surgery department for epigastric and right hypochondria pain, nausea and vomiting. Open cholecystectomy was performed with a trans-cystic tube drainage. Postoperative outcome was favourable but with a continuous decrease in haemoglobin level. In the 13th day postoperatively biliary drainage was 800 ml - haemobilia. Patient health status altered and melena and hematemesis occurred. Endoscopy, cholangiography and abdominal computer tomography (CT) were performed. The episode repeated in day 27 after initial surgery. Duodenotomy and exploration of the biliary tree was performed. Angiography was performed next day that revealed biliary-arterial fistula within segment IV of the liver followed by embolization. Haemobilia reoccurred fifteen days later and colonoscopy and angiography were performed. Embolization with metallic coils was performed. Patient outcome was favourable and was discharged 13 days after second embolization. Interventional angiography remains the first treatment option of haemobilia. Selective arterial ligation or hepatectomy remain the options in case of lack of angiography or insufficient results after embolization.

Massive hemobilia: a diagnostic and therapeutic challenge

BACKGROUND

Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. In this retrospective analysis, we have evaluated the challenges involved in the diagnosis and management of massive hemobilia.

METHODS

Between 2001 and 2011, a total of 20 consecutive patients (14 males) who were treated in our department for massive hemobilia were included in the study and their records were retrospectively analyzed.

RESULTS

Causes of hemobilia were blunt liver trauma (n = 9), hepatobiliary intervention (n = 4), post-laparoscopic cholecystectomy hepatic artery pseudoaneurysm (n = 3), hepatobiliary tumors (n = 3), and vascular malformation (n = 1). Melena, abdominal pain, hematemesis, and jaundice were the leading symptoms. All patients had undergone upper GI endoscopy, abdominal ultrasound, and computerized tomography of the abdomen. An angiogram and therapeutic embolization were done in 12 patients and was successful in nine but failed in three, requiring surgery. Surgical procedures performed were right hepatectomy (n = 4), extended right hepatectomy (n = 1), segmentectomy (n = 1), extended cholecystectomy (n = 1), repair of the pseudoaneurysm (n = 3), and right hepatic artery ligation (n = 1).

CONCLUSION

The successful diagnosis of hemobilia depends on a high index of suspicion for patients with upper GI bleeding and biliary symptoms. Although transarterial embolization is the therapeutic option of choice for massive hemobilia, surgery has a definitive role in patients with hemodynamic instability, after failed embolization, and in patients requiring laparotomy for other reasons.

[Hemobilia into a metallic biliary stent due to pseudoaneurysm: a case report]

A 48-year-old man with locally advanced pancreatic cancer underwent combined treatment with gemcitabine and proton radiation therapy. Because of subsequent obstruction of the common bile duct, a metallic biliary stent was placed and he received further gemcitabine chemotherapy. During chemotherapy, he developed an acute abdomen with a sudden-onset of tarry stool and jaundice. Gastroduodenoscopy revealed hemobilia from the biliary metallic stent. Contrast-enhanced abdominal computed tomography revealed the presence of a pseudoaneurysm arising from the right hepatic artery adjacent to the top of the stent. Hemostasis of the right hepatic artery pseudoaneurysm was achieved via transcatheter arterial embolization using cyanoacrylate.

Haemobilia due to iatrogenic portobiliary fistula after cholecystectomy

Haemobilia, defined as bleeding into the biliary tree is a rare condition. We describe a case report of a patient who presented it as a complication of iatrogenic portobiliary fistula, followed after an open cholecystectomy. The patient presented to the emergency department with late onset symptoms of haematemesis and melena a month after surgery. Findings were confirmed by Doppler ultrasound that showed the appearance of intragallbladder mass with high echogenicity representing a blood clot. Also, next to the portal vein and the biliary duct a lesion with mixed blood flow was detected confirming a portobiliary fistula. This case was successfully managed by angiography and selective embolisation.

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.

[Hemobilia as a late complication after laparoscopic cholecystectomy--endovascular treatment]

A case of 57-year-old woman with hepatic artery pseudoaneurysm associated with fistula into the biliary tract following laparoscopic cholecystectomy. Because of mechanical barrier presence, constricted the blood vessel leading blood into the aneurysm, endovascular embolization with histoacrylate glu was used as a treatment. The use of histoacrylate glu is an effective alternative in hepatic artery pseudoaneurysms treatment, which allowed to get haemostasis by endovascular embolization, especially in cases when it is impossible to use standardly applied microcoils.

Major hemobilia--experience from a specialist unit in a developing country

BACKGROUND AND AIM

Hemobilia is a rare but potentially life threatening problem, which can be difficult to diagnose and treat. In the last few decades there has been a change in the etiologic spectrum and management of this problem in the West. The aim of this study was to analyze the etiology, clinical features, management and outcome of major hemobilia in a tertiary referral centre from western India.

METHODS

A retrospective analysis was undertaken on 22 patients (16 males, 6 females; mean age 39 years, range 13 to 74) who presented with major hemobilia over a 5-year period.

RESULTS

The etiology was iatrogenic in 13 patients (percutaneous transhepatic biliary drainage 8, post laparoscopic cholecystectomy 3, endoscopic retrograde cholangiopancreatography 1, and liver biopsy 1), liver trauma in 6 and liver tumors in 3 patients. Twenty patients presented with gastrointestinal bleeding (melena 20 patients, hemetemesis with melena 8 patients), 5 with jaundice and 8 had fever. Abdominal angiography was performed in 20 patients. Angiography revealed pseudoaneurysm of the right hepatic artery or its branches in 14 patients, left hepatic artery in 2, an arterio-biliary fistula in 1, tumor blush in 1 and the source could not be located in 2 patients. Seventeen of the 22 patients were treated with radiological intervention, 3 required surgery (liver resection for tumors 2, laparotomy for venous collateral bleeding of portal cavernoma 1) and two were managed conservatively. Radiological intervention involved embolisation with coils and/or glue in 16, and chemoembolisation in 1 patient. Sixteen of 17 patients responded to embolisation. Overall there were two deaths.

CONCLUSION

The spectrum of hemobilia seen in India is now similar to that in the developed world with iatrogenic causes being the commonest. Interventional radiology can treat a majority of patients reducing the need and morbidity associated with surgery.

Leaking pseudoaneurysm of hepatic artery: a potentially life-threatening complication of a common procedure

We report a case of leaking pseudoaneurysm of right hepatic artery in a 54-year old female after laparoscopic cholecystectomy who presented with massive gastrointestinal haemorrhage and was successfully managed with angiography and coil embolization.

Complications of endoscopic and radiologic investigation of biliary tract disorders

The investigation and treatment of disorders of the human biliary tree depend considerably on invasive endoscopic and radiologic procedures. These are associated with a significant risk of complications, some of which can be fatal. This review looks at these complications through the lens of 40 years of publications in the medical literature, and identifies the strengths and weaknesses of their current classification, diagnosis, and treatment.

Hemobilia

Hemobilia is an uncommon medical problem that presents in a varied fashion and is increasingly of iatrogenic origin. The diagnosis of hemobilia needs to be considered in patients presenting with upper gastrointestinal bleeding, particularly if they are jaundiced with abdominal pain in the setting of recent or previous percutaneous liver intervention or abdominal trauma. Multislice computed tomographic angiography is increasingly being used in the investigation, but transcatheter arterial embolization remains the cornerstone of managing those patients requiring intervention. The majority of patients with hemobilia will be managed supportively or with radiologic intervention; most do not require surgical intervention.

[Management for pseudoaneurysm of cystic artery with an arterio-biliary fistula after laparoscopic cholecystectomy: a rare case of hemobilia]

Although laparoscopic cholecystectomy is considered to be the gold standard for treatment for symptomatic cholelithiasis, it is associated with an increased risk of biliary and vascular injury compared to the traditional technique. Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. Arterio-biliary fistula is an uncommon cause of hemobilia. We describe a case of cystic artery pseudo-aneurysm causing arterio-biliary fistula and presenting as severe melaena and cholangitis that occurred 7 months after laparoscopic cholecystectomy. Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolization of the pseudo-aneurysm successfully controlled the bleeding. Pseudo-aneurysm of the hepatic artery is mostly iatrogenic due to biliary intervention, as demonstrated in this case. Transarterial embolization is considered the first line of intervention to stop the bleeding for most causes of hemobilia. Hemobilia is a rare complication that should be considered when managing patients with bleeding or jaundice even several months after laparoscopic cholecystectomy.

Small arteriovenous malformation of the common bile duct causing hemobilia in a patient with hereditary hemorrhagic telangiectasia

We report a 54-year-old male patient with arteriovenous malformation located at the common bile duct and hereditary hemorrhagic telangiectasia. The patient was treated as gallstone pancreatitis at first. Three days after endoscopic nasobiliary drainage (ENBD) for biliary drainage to subside gallstone pancreatitis, hemobilia was drained from the ENBD tube and the serum hemoglobin level gradually decreased. Cholangioscopy and angiography revealed that hemobilia was due to a small arteriovenous malformation located at the common bile duct. Subsequently, the patient was successfully treated by endovascular intervention.

[Hemobilia from pancreatic arteriovenous malformation: successful treatment with transportal coil embolization of draining veins]

Pancreatic arteriovenous malformations (AVM) are extremely rare diseases frequently complicated by gastrointestinal hemorrhage. While surgical resection of affected lesion is preferred for the treatment of pancreatic AVM, angiographic intervention can be used as an alternative treatment, especially in surgically high-risk patients. We experienced a patient with pancreatic AVM manifested by hemobilia and biliary sepsis. Superior mesenteric and common hepatic arteriography showed pancreaticoduodenal AVM composed of nidus supplied by numerous fine feeding arteries and of draining veins encircling the common bile duct (CBD). Hemobilia was controlled by transportal coil embolization of draining veins of AVM around the CBD. Herein, we report this case with the review of literatures.

[Hemobilia]

The phenomenon now known as haemobilia was first recorded in XVII century by well known anatomist from Cambridge, Francis Glisson and his description was published in Anatomia Hepatis in 1654. Until today etiology, clinical presentation and management are clearly defined. Haemobilia is a rare clinical condition that has to be considered in differential diagnosis of upper gastrointestinal bleeding. In Western countries, the leading cause of haemobilia is hepatic trauma with bleeding from an intrahepatic branch of the hepatic artery into a biliary duct (mostly iatrogenic in origin, e.g. needle biopsy of the liver or percutaneous cholangiography). Less common causes include hepatic neoplasm; rupture of a hepatic artery aneurysm, hepatic abscess, choledocholithiasis and in the Orient, additional causes include ductal parasitism by Ascaris lumbricoides and Oriental cholangiohepatitis. Clinical presentation of heamobilia includes one symptom and two signs (Quinke triad): a. upper abdominal pain, b. upper gastrointestinal bleeding and c. jaundice. The complications of haemobilia are uncommon and include pancreatitis, cholecystitis and cholangitis. Investigation of haemobilia depends on clinical presentation. For patients with upper gastrointestinal bleeding oesophagogastroduodenoscopy is the first investigation choice. The presence of blood clot at the papilla of Vater clearly indicates the bleeding from biliary tree. Other investigations include CT and angiography. The management of haemobilia is directed at stopping bleeding and relieving biliary obstruction. Today, transarterial embolization is the golden standard in the management of heamobilia and if it fails further management is surgical.

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.

Hepatic artery pseudoaneurysm associated with plastic biliary stent

The increased use of interventional procedures and laparoscopic cholecystectomy in the management of hepatobiliary disorders is associated with an increased incidence of hemobilia and hepatic artery aneurysm. Here we report a case of hepatic artery pseudoaneurysm associated with a plastic biliary stent. Multiple factors were involved in the formation of the hepatic artery aneurysm (HAA) and it was successfully treated by embolization.

Transcatheter arterial embolization in the management of hemobilia

BACKGROUND

This retrospective analysis evaluated the clinical and radiologic results of transcatheter arterial embolization (TAE) in the treatment of significant hemobilia. The imaging findings, embolization technique, complications, and efficacy are described.

METHODS

Thirty-two consecutive patients (21 male, 11 female, age range 8-61 years) who were referred to the radiology department for severe or recurrent hemobilia were treated by TAE. Causes of hemobilia were liver trauma (n = 19; iatrogenic in six and road traffic accident in 13), vasculitis (n = 6), vascular malformations (n = 2), and hepatobiliary tumors (n = 5). Iatrogenic liver trauma was secondary to cholecystectomy in those six patients. Four of five hepatobiliary tumors were inoperable malignant tumors and one was a giant cavernous hemangioma. Arterial embolization was done after placing appropriate catheters as close as possible to the bleeding site. Embolizing materials used were Gelfoam, polyvinyl alcohol particles or steel coils, alone or in combination. Postembolization angiography was performed in all cases to confirm adequacy of embolization. Follow-up color Doppler ultrasound and contrast-enhanced computed tomography was done in all patients.

RESULTS

Ultrasonic, computed tomographic, and angiographic appearances of significant hemobilia were assessed. Angiogram showed the cause of bleeding in all cases. Three patients with liver trauma due to accidents required repeat embolization. Eight patients required surgery due to failed embolization (continuous or repeat bleeding in four patients, involvement of the large extrahepatic portion of hepatic artery in two, and coexisting solid organ injuries in two). Severity of hemobilia did not correlate with grade of liver injury. All 13 patients with blunt hepatic trauma showed the cause of hemobilia in the right lobe. No patient with traumatic hemobilia showed an identifiable cause in the left lobe. There were no clinically significant side effects or complications associated with TAE except one gallbladder infarction, which was noted at surgery, and cholecystectomy was performed with excision of the hepatic artery aneurysm.

CONCLUSION

TAE is a safe and effective interventional radiologic procedure in the nonoperative management of patients who have significant hemobilia.

Management of a rare case of fulminant hemobilia due to arteriobiliary fistula following total pancreatectomy

Hemobilia is a rare cause of acute upper gastrointestinal bleeding and is often associated with a history of hepatic or biliary tract injury, tumor growth, hepatic artery aneurysm, cholecystitis, or hepatic abscess. We report a case of a 76-year-old patient with massive hemobilia due to intrahepatic bleeding from the segment 8 hepatic artery without evidence of a true aneurysm, abscess, or metastatic disease 4 weeks following pylorus-preserving total pancreatectomy for pancreatic cancer. Gastroduodenoscopy suggested hemorrhage from the duodenojejunostomy but failed to achieve hemostasis, and the patient underwent exploratory laparotomy. It was realized intraoperatively that the bleeding originated from the intrahepatic biliary tract. Bleeding was controlled by blocking the right hepatic bile duct with a Fogarty catheter and subsequent transarterial embolization. Computed tomography did not reveal any local liver or vascular pathology. Retrospectively, the cause of delayed profuse hemobilia was most likely a traumatic intrahepatic pseudoaneurysm following endoscopic bile duct stenting 3 weeks before the pancreatectomy. The reported case is exceptional and of particular interest because of the absence of a typical history or cause of hemobilia, preoperative misleading diagnostic results in an altered anatomic situation, and the operative management to achieve bleeding control in this emergency setting.

Utility of Stent-Grafts in Treatment of Porto-Biliary Fistula

A porto-biliary fistula causing hemobilia is a known complication of percutaneous transhepatic biliary drainage (PTBD). We present two patients with hemobilia secondary to porto-biliary fistula, treated successfully by percutaneous placement of stent-grafts. In one case, the stent-graft was placed in the bile duct, and in the other case, it was placed in the intrahepatic portal vein branch. Hemobilia stopped and there were no complications except a small area of hepatic infarction, distal to the stent-graft in the portal vein.

Hepatic artery embolization to control liver hemorrhages by interventional radiologists: experiences from Khon Kaen University

Between 2001 and 2005, nine patients with liver hemorrhage underwent non-surgical embolotherapy. There were six males and three females, ranging in age from 9 to 58 years. All patients were symptomatic with hypotension and decreasing hematocrit. Causes of liver hemorrhage included liver laceration following blunt abdominal injury (2 patients), pseudoaneurysms of hepatic artery following blunt abdominal trauma (4 patients), post-traumatic hepatic artery and portal vein pseudoaneurysm (1 patient), hemobilia following liver resection for cholangiocarcinoma (1 patient) and hepatic artery aneurysm with fistula to the common bile duct (1 patient). All patients had successful embolization of artery to control liver hemorrhage. No acute complication occurred. In conclusion, embolotherapy is an effective treatment with a low complication rate to stop liver hemorrhage, especially from an artery.

Hepatic artery aneurysm presenting with hemobilia in a patient with Behçet's disease: treatment with percutaneous transcatheteral embolization

We herein report a case of hemobilia caused by a hepatic artery aneurysm. A 40-year-old male patient with a history of Behçet's disease with a thrombus hanging out of the papilla of Vater had a large hepatic aneurysm in angiography. The hepatic artery feeding the aneurysm was embolized. Endovascular treatment can treat patients with hepatic artery aneurysms caused by Behçet's disease.

Non-operative management of endoscopic iatrogenic haemobilia: case report and review of literature

Haemobilia denotes an abnormal communication between a vessel of the splanchnic circulation and the biliary system. Patients typically presents with the triad of abdominal pain, upper gastrointestinal haemorrhage, and jaundice. Common causes for haemobilia are iatrogenic causes secondary to hepatobiliary system instrumentation and trauma. Management of patients with haemodynamic significant haemobilia is aimed at stopping bleeding, maintaining continuous flow of biliary system, and cure of the underlying aetiology. Iatrogenic haemobilia after ERCP polyethylene biliary endoprosthesis placement is extremely uncommon. Herein we present a case of iatrogenic haemobilia triggered by biliary endoprosthesis placement and was successfully managed by non-operative treatment. The management algorithm for a rational approach to haemobilia is discussed.

Evaluation of selective hepatic angiography and embolization in patients with massive hemobilia

BACKGROUND

Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. Transarterial embolization is considered the first line of intervention to stop the bleeding for most causes of hemobilia. This study was conducted to evaluate selective hepatic angiography and embolization in the diagnosis and treatment of patients with massive hemobilia.

METHODS

The clinical data of 16 patients with massive hemobilia were analyzed retrospectively. These patients underwent emergency celiac and selective right or left hepatic artery angiography and treated by embolization using Gelfoam particles and/or coils.

RESULTS

Hepatic artery angiography revealed hepatic artery pseudoaneurysms in 6 patients, cystic artery pseudoaneurysms in 2, diffuse hemorrhage of hepatic artery branches in 5, and right hepatic artery-bile duct fistulae in 3. The patients were diagnosed rapidly by angiography and treated successfully by embolization of the hepatic artery branch proximal to the bleeding point, and hemorrhage was stopped immediately. Two patients were embolized the second time for rebleeding. Neither recurrence of bleeding nor serious complication was found during the follow-up for 3 months to 2 years. The other 2 patients whose hemorrhage failed to be controlled died several days later.

CONCLUSION

Being safe, reliable and minimally invasive, selective hepatic artery angiography and embolization are effective in the diagnosis and treatment of massive hemobilia.

Incidence of important hemobilia following transhepatic biliary drainage: left-sided versus right-sided approaches

Our purpose here is to describe our experience with important hemobilia following PTBD and to determine whether left-sided percutaneous transhepatic biliary drainage (PTBD) is associated with an increased incidence of important hemobilia compared to right-sided drainages. We reviewed 346 transhepatic biliary drainages over a four-year period and identified eight patients (2.3%) with important hemobilia requiring transcatheter embolization. The charts and radiographic files of these patients were reviewed. The side of the PTBD (left versus right), and the order of the biliary ductal branch entered (first, second, or third) were recorded. Of the 346 PTBDs, 269 were right-sided and 77 were left-sided. Of the eight cases of important hemobilia requiring transcatheter embolization, four followed right-sided and four followed left-sided PTBD, corresponding to a bleeding incidence of 1.5% (4/269) for right PTBD and 5.2% (4/77) for left PTBD. The higher incidence of hemobilia associated with left-sided PTBD approached, but did not reach the threshold of statistical significance (p = 0.077). In six of the eight patients requiring transcatheter embolization, first or second order biliary branches were accessed by catheter for PTBD. All patients with left-sided bleeding had first or proximal second order branches accessed by biliary drainage catheters. In conclusion, a higher incidence of hemobilia followed left-versus right-sided PTBD in this study, but the increased incidence did not reach statistical significance.

Hemobilia as presenting manifestation of polyarteritis nodosa

Polyarteritis nodosa (PAN) is a multisystem necrotizing inflammatory vasculitis of medium-sized muscular arteries. Hepatobiliary complications secondary to thrombosis or aneurysm formation in PAN are rare and are associated with poor outcome. We describe an 18-year-old man with PAN who presented with hemobilia secondary to rupture of a hepatic artery aneurysm, which was successfully managed with coil embolization followed by immunosuppressive therapy.

[A child with traumatic hemobilia]

A 4-year-old boy was hit by a car travelling at 40 km/h and was admitted 3.5 h later to the department of paediatric surgery. Because he was haemodynamically unstable and needed blood transfusion, the patient underwent an emergency operation. The liver was ruptured in the right lobe. A large haematoma was found in the serosa of the duodenum, along with a Meckel's diverticle, which was left in place. The liver rupture was covered and sealed. One month after the accident the patient was re-admitted, because of abdominal pain and gastrointestinal bleeding. The cause was thought to be the Meckel's diverticle, which was removed later. Two months after the trauma the patient was re-admitted with abdominal pain, again with haematemesis and melaena. The diagnosis of hemobilia was obtained with MRI and angiography, which revealed a ruptured pseudoaneurysm of the ramus dexter of the proper hepatic artery. The patient was successfully treated with embolization. The diagnostic delay was two months, which illustrates the importance of considering the possibility of the diagnosis hemobilia in case of gastrointestinal haemorrhage combined with biliary symptoms.

Hemobilia secondary to chronic cholecystitis

The term hemobilia is used to describe the presence of blood in the biliary tract. We report a case of symptomatic hemobilia associated with chronic cholecystitis in a 57-year-old man with jaundice, gastrointestinal hemorrhage, and epigastric pain. We review the etiology of this condition and highlight the role of abdominal ultrasonography in its diagnosis. In our case, abdominal ultrasonography revealed the presence of clots inside the gallbladder. The clinical condition was resolved by means of a cholecystectomy. The patient had an uneventful recovery.