Hemobilia como causa infrecuente y grave de hemorragia digestiva alta / Hemobilia as a rare and serious cause of upper gastrointestinal bleeding

Introducción: La hemobilia es por definición una causa de hemorragia digestiva alta, donde existe una comunicación de la vía biliar en cualquiera de sus segmentos con vasos sanguíneos que desembocan a través de la ampolla de Vater. Su presentación es infrecuente y no sospechada en la práctica clínica diaria de gastroenterólogos, cirujanos, hepatólogos, clínicos e intensivistas, con un difícil manejo diagnóstico-terapéutico y una elevada morbi-mortalidad. Objetivo: Describir tres casos de pacientes con diagnóstico de hemobilia. Desarrollo: Se presentan tres casos con hemobilia que tuvieron una elevada mortalidad y con diferente etiología; en el primer caso por trombosis de la arteria hepática postrasplante hepático, el segundo secundario a un colangiocarcinoma de la unión hepatocística y el tercero con diagnóstico de un aneurisma de la arteria hepática derecha confirmado y parcialmente tratado por angiotomografía, posteriormente intervenido quirúrgicamente y único sobreviviente. Conclusiones: Resultaron tres casos con hemobilia de diferentes causas, con una elevada mortalidad por la intensidad de la hemorragia digestiva alta y las comorbilidades asociadas, además de señalar que ninguno de ellos presentó la tríada clásica reportada por Quincke(AU)

Introduction: Hemobilia is, by definition, a cause of upper gastrointestinal bleeding, where there is a communication of the bile duct in any of its segments with blood vessels that flow through the ampulla of Vater. It is rare and it is not suspected in the daily clinical practice of gastroenterologists, surgeons, hepatologists, clinicians and intensivists, hence the diagnostic-therapeutic management is difficult and it has high morbidity and mortality. Objective: To report three cases of patients with a diagnosis of hemobilia. Case report: We report three cases of hemobilia of high mortality and different etiology. The first case had post-liver transplantation hepatic artery thrombosis, the second had asecondary cholangiocarcinoma of the hepatocystic junction and the third had diagnosis of confirmed right hepatic artery aneurysm partially treated by CT angiography, subsequently operated on and the only survivor. Conclusions: These three hemobilia cases had different causes, and high mortality due to the intensity of the upper gastrointestinal bleeding and the associated comorbidities, in addition to noting that none of them exhibited the classic triad reported by Quincke(AU)

Hemobilia, una causa infrecuente de hemorragia del tracto digestivo superior / Hemobilia, a rare cause of upper gastrointestinal bleeding

Resumen La hemobilia es una causa poco frecuente de hemorragia del tracto gastrointestinal superior. La principal etiología es de origen iatrogénico y la posibilidad de hemobilia debe considerarse en cualquier paciente con hemorragia gastrointestinal y un historial reciente de procedimientos hepatobiliares. Otras causas menos frecuentes incluyen el trauma de abdomen, la enfermedad oncológica de la vía biliar o las enfermedades inflamatorias del páncreas o la vía biliar. La presentación clínica varía según la gravedad del sangrado; generalmente se presenta con dolor abdominal, ictericia y melenas, aunque puede cursar al ingreso con rectorragia e hipotensión. Un alto porcentaje de estas presenta resolución espontánea, sin requerir procedimientos adicionales. La angiografía es el estándar de oro para el diagnóstico de la hemobilia, pero los avances en la angiotomografía permiten que esta sea una opción menos invasiva y con mayor disponibilidad. La angioembolización es el tratamiento principal para estos pacientes, pero existen otras alternativas como la colocación de stent vascular o de stent en el conducto biliar.

Abstract Hemobilia is a rare cause of upper gastrointestinal (GI) tract bleeding. Its main etiology is iatrogenic, and the possibility of hemobilia should be considered in any patient with GI bleeding and a recent history of hepatobiliary surgery. Other less frequent causes include abdominal trauma, oncologic disease of the biliary tract, or inflammatory diseases of the pancreas or bile duct. Its clinical presentation varies depending on the severity of the bleeding. It usually presents with abdominal pain, jaundice, and tarry stools, although patients may also present with rectorrhagia and hypotension on admission. A high percentage of these symptoms have a spontaneous resolution, without requiring additional procedures. Angiography is the gold standard for the diagnosis of hemobilia, but advances in computed tomography angiography make it a less invasive and more widely available option. Endovascular embolization is the main treatment for these patients, but there are other alternatives such as vascular or bile duct stent placement.

Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction

OBJECTIVE: To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO). MATERIALS AND METHODS: From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival. RESULTS: A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186−237 days) and 141 days (95% CI, 126−156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival. CONCLUSION: Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

A Ruptured Cystic Artery Pseudoaneurysm with Concurrent Cholecystoduodenal Fistula: A Case Report and Literature Review

Pseudoaneurysms of the cystic artery and cholecystoduodenal fistula formation are rare complications of cholecystitis and either may result from an inflammatory process in the abdomen. A 68-year-old man admitted with acute cholecystitis subsequently developed massive upper gastrointestinal (GI) bleeding. Abdominal computed tomography showed acute calculous cholecystitis and hemobilia secondary to bleeding from the cystic artery. Angiography suggested a ruptured pseudoaneurysm of the cystic artery. Upper GI endoscopy showed a deep active ulcer with an opening that was suspected to be that of a fistula at the duodenal bulb. The patient was managed successfully with multimodality treatment that included embolization followed by elective laparoscopic cholecystectomy. Presently, there is no clear consensus regarding the clinical management of this disease. We have been able to confirm various clinical features, diagnoses, and treatments of this disease through a literature review. A multidisciplinary approach through interagency/interdepartmental collaboration is necessary for better management of this disease.

Double-Stent System with Long Duodenal Extension for Palliative Treatment of Malignant Extrahepatic Biliary Obstructions: A Prospective Study

OBJECTIVE: To investigate the technical safety and clinical efficacy of a double-stent system with long duodenal extension in patients with malignant extrahepatic biliary obstruction. MATERIALS AND METHODS: This prospective study enrolled 48 consecutive patients (31 men, 17 women; mean age, 61 years; age range, 31–77 years) with malignant extrahepatic biliary obstructions from May 2013 to December 2015. All patients were treated with a double-stent system with long duodenal covered extension (16 cm or 21 cm). RESULTS: The stents were successfully placed in all 48 patients. There were five (10.4%) procedure-related complications. Minor complications were self-limiting hemobilia (n = 2). Major complications included acute pancreatitis (n = 1) and acute cholecystitis (n = 2). Successful internal drainage was achieved in 42 (87.5%) patients. Median patient survival and stent patency times were 92 days (95% confidence interval [CI], 61–123 days) and 83 days (95% CI, 46–120 days), respectively. Ten (23.8%) of the 42 patients presented with stent occlusion due to food impaction with biliary sludge, and required repeat intervention. Stent occlusion was more frequent in metastatic gastric cancer patients with pervious gastrectomy, but did not reach statistical significance (p = 0.069). CONCLUSION: Percutaneous placement of a double-stent system with long duodenal extension is feasible and safe. However, this stent system does not completely prevent stent occlusion caused by food reflux.

Coil embolization of ruptured intrahepatic pseudoaneurysm through percutaneous transhepatic biliary drainage / 영남의대학술지

A 75-year-old man with chronic cholangitis and a common bile duct stone that was not previously identified was admitted for right upper quadrant pain. Acute cholecystitis with cholangitis was suspected on abdominal computed tomography (CT); therefore, endoscopic retrograde cholangiopancreatography with endonasal biliary drainage was performed. On admission day 5, hemobilia with rupture of two intrahepatic artery pseudoaneurysms was observed on follow-up abdominal CT. Coil embolization of the pseudoaneurysms was conducted using percutaneous transhepatic biliary drainage. After several days, intrahepatic artery pseudoaneurysm rupture recurred and coil embolization through a percutaneous transhepatic biliary drainage tract was conducted after failure of embolization via the hepatic artery due to previous coiling. After the second coil embolization, a common bile duct stone was removed, and the patient presented no complications during 4 months of follow-up. We report a case of intrahepatic artery pseudoaneurysm rupture without prior history of intervention involving the hepatobiliary system that was successfully managed using coil embolization through percutaneous transhepatic biliary drainage.

Hemobilia secundaria a aneurisma de la arteria hepática / Hemobilia Secondary to Aneurysm of the Hepatic Artery

Resumen Se presenta el caso de un paciente con hemorragia de vías digestivas altas e ictericia asociadas a un aneurisma de la arteria hepática derecha.

Abstract We present the case of a patient with upper digestive tract hemorrhaging and jaundice due to an aneurysm of the right hepatic artery.

An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications

Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%–45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques—such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy—combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.

Pancreaticoduodenal artery pseudoaneurysm-induced hemobilia caused by a plastic biliary stent

SUMMARY OF EVENT: Melena with abdominal pain were developed in a patient who had undergone endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct stones removal and endoscopic retrograde biliary drainage (ERBD) using a plastic biliary stent. He subsequently underwent laparoscopic cholecystectomy. For the diagnosis and treatment of hemobilia caused by a plastic biliary stent, selective angiography for gastroduodenal artery with subsequent embolization for small pseudoaneurysm of pancreaticoduodenal artery was done successfully. TEACHING POINT: A plastic biliary stent induced pseudoaneurysm can be a cause of hemobilia after ERCP with ERBD procedure. Selective angiography with embolization for bleeding pseudoaneurysm can be an effective treatment for this situation.

Post-Endoscopic Sphincterotomy Bleeding: Strategic Approach with Multiple Endoscopic Arms / 대한췌담도학회지

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential method for diagnosis and treatment of various pancreatobiliary diseases and endoscopic sphincterotomy (EST) is the gateway to complete ERCP. Although techniques and instruments for EST have improved, bleeding is still the most common complication. Treatment of immediate post-EST bleeding is important because blood can interfere with subsequent procedures. Additionally, endoscopists should be cautious about delayed bleeding may cause hemobilia, cholangitis, and hemodynamic shock. Most cases of post-EST bleedings will stop spontaneously, however, endoscopic management is necessary in case of clinically significant and persistent bleeding. Various endoscopic methods including epinephrine or fibrin glue injection, electrocoagulation, hemoclipping and band ligation et al can be used through a sideviewing or forward-viewing endoscope similar to those used in hemostasis of peptic ulcer bleeding. Endoscopists who perform ERCP should use various methods of endoscopic hemostasis strategically.

Post-Endoscopic Sphincterotomy Bleeding: Strategic Approach with Multiple Endoscopic Arms / 대한췌담도학회지

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential method for diagnosis and treatment of various pancreatobiliary diseases and endoscopic sphincterotomy (EST) is the gateway to complete ERCP. Although techniques and instruments for EST have improved, bleeding is still the most common complication. Treatment of immediate post-EST bleeding is important because blood can interfere with subsequent procedures. Additionally, endoscopists should be cautious about delayed bleeding may cause hemobilia, cholangitis, and hemodynamic shock. Most cases of post-EST bleedings will stop spontaneously, however, endoscopic management is necessary in case of clinically significant and persistent bleeding. Various endoscopic methods including epinephrine or fibrin glue injection, electrocoagulation, hemoclipping and band ligation et al can be used through a sideviewing or forward-viewing endoscope similar to those used in hemostasis of peptic ulcer bleeding. Endoscopists who perform ERCP should use various methods of endoscopic hemostasis strategically.

Delayed Severe Hemobilia after Endoscopic Biliary Plastic Stent Insertion

Hemobilia is a rare gastrointestinal bleeding, usually caused by injury to the bile duct. Hemobilia after endoscopic retrograde cholangiopancreatography (ERCP) is generally self-limiting and patients will spontaneously recover, but some severe and fatal hemorrhages have been reported. ERCP-related bowel or bile duct perforation should be managed promptly, according to the type of injury and the status of the patient. We recently experienced a case of late-onset severe hemobilia in which the patient recovered after endoscopic biliary stent insertion. The problem was attributable to ERCP-related bile duct perforation during stone removal, approximately 5 weeks prior to the hemorrhagic episode. The removal of the stent was performed 10 days before the onset of hemobilia. The bleeding was successfully treated by two sessions of transarterial coil embolization.

Hemobilia pós-trauma: forma não usual de hemorragia digestiva alta - relato de caso / Hemobilia post-trauma: unusual form of upper gastrointestinal bleeding - case report

A hemobilia é definida como o sangramento no trato biliar e representa uma causa rara de hemorragia digestiva alta. Sua etiologia é variada, sendo majoritariamente devido a trauma acidental e iatrogenia, e o seu tratamento padrão ouro consiste na embolização seletiva da artéria hepática. Os autores relatam o caso de um paciente de 19 anos, do sexo masculino, vítima de uma queda de 5 metros de altura. Após tomografia computadorizada de abdome, foi evidenciada lesão hepática e optado por tratamento conservador. Paciente recebeu alta hospitalar com ultrassonografia de abdome, evidenciando estabilidade da lesão e retornou após 43 dias do trauma apresentando dor epigástrica e hematêmese. Tomografia computadorizada contrastada de abdome evidenciou a presença de pseudoaneurisma de artéria hepática direita, sendo optado pela embolização. Desse modo, apesar de não ser frequente, hemobilia é uma hipótese a qual deve sempre ser considerada em pacientes com hemorragia digestiva alta que sofreram trauma acidental ou foram submetidos a algum tipo de procedimento envolvendo a árvore biliar.

Hemobilia is defined as bleeding in the biliary tract, and is a very rare cause of upper gastrointestinal bleeding. Its etiology is varied (mostly due to accidental trauma and iatrogenic) and its gold standard treatment is selective hepatic artery embolization. The authors report a case of a 19 year old patient, male, victim of a fall of 5 meters high. After computed tomography of the abdomen, liver damage was observed and opted for conservative treatment. Patient was discharge with abdominal ultrasonography demonstrating stability of the injury and returned after 43 days of trauma presenting epigastric pain and hematemesis. Contrasted computed tomography of the abdomen showed the presence of pseudoaneurysm of right hepatic artery and opted for embolization. Thus, although it is unusual, it is a hypothesis that must always be considered in patients with upper gastrointestinal bleeding who have suffered accidental trauma or underwent some kind of procedure involving the biliary tree.

Ruptured Cystic Artery Pseudoaneurysm as a Rare Cause of Massive Hemobilia / 대한췌담도학회지

Gastrointestinal bleeding from the biliary tree, called hemobilia, is an uncommon event. It may clinically present as hematemesis or melena. Ruptured cystic artery pseudoaneurysm is a rare cause of hemobilia, with 2 cases reported in Korea. We present this unusual condition in a 65-year-old man whose chief complaint was abdominal pain. His final diagnosis was ruptured cystic artery pseudoaneurysm, and he was successfully treated by transcatheter arterial embolization and laparoscopic cholecystectomy.

The Clinical Usefulness of Simultaneous Placement of Double Endoscopic Nasobiliary Biliary Drainage

BACKGROUND/AIMS: To evaluate the technical feasibility and clinical efficacy of double endoscopic nasobiliary drainage (ENBD) as a new method of draining multiple bile duct obstructions. METHODS: A total of 38 patients who underwent double ENBD between January 2004 and February 2010 at the Asan Medical Center were retrospectively analyzed. We evaluated indications, laboratory results, and the clinical course. RESULTS: Of the 38 patients who underwent double ENBD, 20 (52.6%) had Klatskin tumors, 12 (31.6%) had hepatocellular carcinoma, 3 (7.9%) had strictures at the anastomotic site following liver transplantation, and 3 (7.9%) had acute cholecystitis combined with cholangitis. Double ENBD was performed to relieve multiple biliary obstruction in 21 patients (55.1%), drain contrast agent filled during endoscopic retrograde cholangiopancreatography in 4 (10.5%), obtain cholangiography in 4 (10.5%), drain hemobilia in 3 (7.9%), relieve Mirizzi syndrome with cholangitis in 3 (7.9%), and relieve jaundice in 3 (7.9%). CONCLUSIONS: Double ENBD may be useful in patients with multiple biliary obstructions.

Percutaneous Unilateral Biliary Metallic Stent Placement in Patients with Malignant Obstruction of the Biliary Hila and Contralateral Portal Vein Steno-Occlusion

OBJECTIVE: To investigate the outcomes of percutaneous unilateral metallic stent placement in patients with a malignant obstruction of the biliary hila and a contralateral portal vein steno-occlusion. MATERIALS AND METHODS: Sixty patients with a malignant hilar obstruction and unilobar portal vein steno-occlusion caused by tumor invasion or preoperative portal vein embolization were enrolled in this retrospective study from October 2010 to October 2013. All patients were treated with percutaneous placement of a biliary metallic stent, including expanded polytetrafluoroethylene (ePTFE)-covered stents in 27 patients and uncovered stents in 33 patients. RESULTS: A total of 70 stents were successfully placed in 60 patients. Procedural-related minor complications, including self-limiting hemobilia (n = 2) and cholangitis (n = 4) occurred in six (10%) patients. Acute cholecystitis occurred in two patients. Successful internal drainage was achieved in 54 (90%) of the 60 patients. According to a Kaplan-Meier analysis, median survival time was 210 days (95% confidence interval [CI], 135-284 days), and median stent patency time was 133 days (95% CI, 94-171 days). No significant difference in stent patency was observed between covered and uncovered stents (p = 0.646). Stent dysfunction occurred in 16 (29.6%) of 54 patients after a mean of 159 days (range, 65-321 days). CONCLUSION: Unilateral placement of ePTFE-covered and uncovered stents in the hepatic lobe with a patent portal vein is a safe and effective method for palliative treatment of patients with a contralateral portal vein steno-occlusion caused by an advanced hilar malignancy or portal vein embolization. No significant difference in stent patency was detected between covered and uncovered metallic stents.

Anticoagulant Therapy-Induced Gallbladder Hemorrhage after Cardiac Valve Replacement

Anticoagulation therapy is essential after cardiac valve surgery. However, spontaneous bleeding remains a major concern during anticoagulation therapy. Spontaneous gallbladder (GB) hemorrhage (hemobilia) is a rare occurrence during standard anticoagulation therapy. This report presents a case of GB hemorrhage that occurred shortly after initiating oral anticoagulant therapy in a patient who had undergone mitral valve replacement surgery.

Life-threatening Hemobilia following Removal of a Biliary Stent in a Patient with a Bile Leak / 대한췌담도학회지

Biliary plastic stent induced life-threatening hemobilia is very rare. In this case, hemobilia seriously worsened following removal of a biliary stent, which had been placed for treatment of a postoperative bile leak in a patient who had undergone lateral liver segmentectomy for abdominal trauma. Following placement of the biliary stent, the bile leak improved, but hemobilia and cholangitis developed five days later. To manage the stent malfunction, we removed the biliary stent. However, life-threatening hemobilia developed immediately after removal. Endoscopic hemostasis was impossible; therefore, emergency angiographic embolization and stent graft were performed successfully. In such cases, angiographic embolization and stent-graft placement are effective diagnostic and therapeutic alternatives. When a patient develops hemobilia or cholangitis after biliary stent placement, endoscopists should pay special attention to remove the stent, which might exacerbate hemobilia.

A Case of Massive Hemobilia after a Long Period of Time Since Open Cholecystectomy / 대한췌담도학회지

A 77-year-old woman was admitted with 5 days history of melena. She had an open cholecystectomy 30 years ago. Abdominal computed tomography and duodenoscopy revealed massive hemobilia. Angiography showed right hepatic arterial fistula to common bile duct near the surgical clip. Embolization was done successfully and the patient recovered. We experienced a case of a massive hemobilia which was occurred after a long period of time since open cholecystectomy without pseudoaneurysmal change of the right hepatic artery. And we suggest the direct vessel injury and fistula between the bile duct and a blood vessel as a possible cause of hemobilia in this case.

Papilomatose da vesícula biliar associada à leucodistrofia metacromática, uma causa rara de hemobilia não traumática / Papillomatosis of the gallbrander associated with metachromatic leukodystrophy, a rarre cause of nontraumatic hemobilia

A principal causa de hemobilia é a lesão traumática de ramos intra-hepáticos da artéria hepática. Porém, outras etiologias são descritas. O objetivo deste artigo é apresentar uma rara causa de hemorragia digestiva secundária à hemobilia associada à leucodistrofia metacromática. Revisão bibliográfica evidenciou apenas quatro casos descritos.

The main cause of hemobilia is the traumatic injury of intrahepatic branches of the hepatic artery. However, other etiologies are decribed. The objective of this paper is to present a rare case of gastrointestinal bleeding secondary to hemobilia associated with metachromatic leukodystrophy. Literature review revealed only four cases described.