Rapid identification of source of delayed hemobilia following endoscopic metallic stenting for malignant biliary obstruction.

Delayed hemobilia, a rare but potentially fatal complication of endoscopic metallic stenting for malignant biliary obstruction, requires prompt identification of the source of bleeding and subsequent embolization. However, hemobilia is characteristically intermittent, and computed tomography (CT) often fails to show pseudoaneurysms or extravasations. In particular, because the posterior superior pancreaticoduodenal artery (PSPDA) runs alongside the common bile duct for its whole length, it is readily obscured by metallic artifacts in that duct, such as stents, making identification of the source of bleeding by CT difficult. We have encountered three patients with delayed hemobilia from the PSPDA following endoscopic biliary stenting for malignant biliary obstruction in whom no extravasation or pseudoaneurysms were detected by contrast-enhanced CT during bleeding. However, when we identified that the PSPDA had a smaller diameter than in previous CTs in all three cases, we suspected that the PSPDA was the source of the bleeding. No extravasation or pseudoaneurysms were detected with celiac arteriography or superior mesenteric arteriography; however, extravasation and pseudoaneurysms were detected by direct PSPDA angiography. Hemostasis was achieved through embolization. Detecting a large decrease in the diameter of the PSPDA on contrast-enhanced CT during biliary bleeding may help to identify the source of that bleeding.

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.

Transcatheter arterial embolization for massive hemobilia with N-butyl cyanoacrylate (NBCA) Glubran 2.

BACKGROUND: Massive hemobilia is a life-threatening condition and therapeutic challenge. Few studies have demonstrated the use of N-butyl cyanoacrylate (NBCA) for massive hemobilia. PURPOSE: To investigate the efficacy and safety of transcatheter arterial embolization (TAE) using NBCA Glubran 2 for massive hemobilia. MATERIAL AND METHODS: Between January 2012 and December 2019, the data of 26 patients (mean age 63.4 ± 12.6 years) with massive hemobilia were retrospectively evaluated for TAE using NBCA. The patients' baseline characteristics, severities of hemobilia, and imaging findings were collected. Emergent TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil. Technical success, clinical success, procedure-related complications, and follow-up outcomes were assessed. RESULTS: Pre-procedure arteriography demonstrated injuries to the right hepatic artery (n = 24) and cystic artery (n = 2). Initial coil embolization distal to the lesions was required in 5 (19.2%) patients to control high blood flow and prevent end-organ damage. After a mean treatment time of 11.2 ± 5.3 min, technical success was achieved in 100% of the patients without non-target embolization and catheter adhesion. Clinical success was achieved in 25 (96.2%) patients. Major complications were noted in 1 (3.8%) patient with gallbladder necrosis. During a median follow-up time of 16.5 months (range 3-24 months), two patients died due to carcinomas, whereas none of the patients experienced recurrent hemobilia, embolic material migration, or post-embolization complications. CONCLUSION: NBCA embolization for massive hemobilia is associated with rapid and effective hemostasis, as well as few major complications. This treatment modality may be a promising alternative to coil embolization.

Haemobilia secondary to an arterio-biliary fistula: A rare complication of intra-operative microwave ablation of hepatocellular carcinoma.

A rare case of arterio-biliary fistula and haemobilia complicating intra-operative microwave ablation of hepatocellular carcinoma in a 58-year-old woman with cirrhosis.

Challenges in Diagnosis and Management of Hemobilia.

Hemobilia, or hemorrhage within the biliary system, is an uncommon form of upper gastrointestinal (GI) bleeding that presents unique diagnostic and therapeutic challenges. Most cases are the result of iatrogenic trauma, although accidental trauma and a variety of inflammatory, infectious, and neoplastic processes have also been implicated. Timely diagnosis can often be difficult, as the classic triad of upper GI hemorrhage, biliary colic, and jaundice is present in a minority of cases, and there may be considerable delay in the onset of bleeding after the initial injury. Therefore, the radiologist must maintain a high index of suspicion for this condition and be attuned to its imaging characteristics across a variety of modalities. CT is the first-line diagnostic modality in evaluation of hemobilia, while catheter angiography and endoscopy play vital and complementary roles in both diagnosis and treatment. The authors review the clinical manifestations and multimodality imaging features of hemobilia, describe the wide variety of underlying causes, and highlight key management considerations.©RSNA, 2021.

Revisiting Quincke's Triad: A Case of Idiopathic Hepatic Artery Aneurysm Presenting with Obstructive Jaundice.

INTRODUCTION: Hepatic artery aneurysm (HAA) is a rare occurrence. Quincke's triad of hemobilia; abdominal pain, obstructive jaundice, and upper gastrointestinal (GI) bleeding could be detected in one-third of HAA patients. CASE PRESENTATION: We present a case of HAA with all signs of Quincke's triad and shock. The diagnosis of HAA was enforced by CT angiography. An urgent open surgical approach was elected by the surgical team. The patient underwent an uneventful resection of the HAA, and primary repair of the CHA followed with bilioenteric reconstruction. CONCLUSIONS: Recognizing the signs of Quincke's triad aids in prompt diagnosis of hemobilia in HAA, which suggests a rupture of the aneurysm or fistula formation into the biliary tree that would need urgent management by both vascular and HBP surgeons.

Active bleeding due to a hepatic arterial pseudoaneurysm that occurred after acute cholangitis.

We read with interest the article by Guido Villa-Gómez, Manuel Alejandro Mahler and Dante Manazzoni "A new case of pseudoaneurysm of the right hepatic artery secondary to laparoscopic cholecystectomy". A 57-year-old cholecystectomized female was admitted due to abdominal pain with an analytical pattern of cholestasis and liver enzyme alterations, with cholangitis that progressed to septic shock of a biliary origin with gradual anemia and hypotension.

Isolated gallbladder injury from blunt abdominal trauma: A rare co-incidence.

Gallbladder injury resulting from blunt abdominal trauma is a rare entity and generally associated with other intra-abdominal injuries. Incidence of isolated gallbladder injury has not been reported yet. The most common mechanism of injury reported is road traffic accident. Diagnosis is usually made on imaging as clinical presentation may vary from no symptoms to peritonitis due to extravasation of bile in the abdominal cavity. Cholecystectomy is the treatment of choice and minimally invasive approach can be considered in haemodynamically stable patients.

Triple Covered Metal Stent Deployment Using Side-by-Side Technique for Hemobilia due to Hepatocellular Carcinoma (with Video).

A hepatocellular carcinoma (HCC) rarely expands into the biliary tract. In this situation, because of its hypervascular nature, cholangitis or hemobilia may sometimes occur. Surgery is one of the options in this situation. However, patients with HCC and bile duct invasion are sometimes in a poor general condition, as in the case presented in this report. For such patients, surgical treatment may need to be invasive. Thus, here we report technical tips for triple covered metal stent deployment using side-by-side technique for hemobilia due to HCC. After guidewire deployments at the left, anterior, and posterior bile ducts, 6-mm covered self-expandable metal stents were placed at each bile duct. This may be useful for high-grade hepatic hilar obstruction due to HCC because drainage and hemostasis effects are obtained.

Embolization for delayed arterial bleeding after percutaneous self-expandable metallic stent placement in patients with malignant biliary obstruction.

OBJECTIVES: To retrospectively evaluate the safety and efficacy of transcatheter arterial embolization (TAE) for delayed arterial bleeding secondary to percutaneous self-expandable metallic stent (SEMS) placement in patients with malignant biliary obstruction (MBO). METHODS: From January 1997 to September 2017, 1858 patients underwent percutaneous SEMS placement for MBO at a single tertiary referral center. Among them, 19 patients (mean age, 70.2 [range, 52-82] years; 13 men) presented with delayed SEMS-associated arterial bleeding and underwent TAE. RESULTS: The incidence of delayed arterial bleeding was 1.0% (19/1858) after SEMS placement, with a median time interval of 225 days (range, 22-2296). Digital subtraction angiography (DSA) showed pseudoaneurysm alone close to the stent mesh (n = 10), pseudoaneurysm close to the stent mesh with contrast extravasation to the duodenum (n = 3), pseudoaneurysm close to the stent mesh with arteriobiliary fistula (n = 1), in-stent pseudoaneurysm alone (n = 4) and in-stent pseudoaneurysm with arteriobiliary fistula (n = 1). Bleeding was stopped after the embolization in all patients. Overall clinical success rate was 94.7% (18/19). One patient with recurrent bleeding was successfully treated with a second embolization. Overall 30-day mortality rate was 26.3% (5/19). A major procedure-related complication was acute hepatic failure in one hilar bile duct cancer patient (5.3%), which was associated with an obliterated portal vein. CONCLUSION: TAE is safe and effective for the treatment of delayed arterial bleeding after percutaneous SEMS placement for MBO. ADVANCES IN KNOWLEDGE: This study demonstrated TAE is safe and effective for arterial bleeding after SEMS placement after MBO through the largest case series so far.

Massive hemobilia due to a ruptured mycotic hepatic artery aneurysm associated with streptococcal endocarditis: case report.

Hepatic artery aneurysm rupture is a rare cause of massive hemobilia, which is potentially life-threatening, cause of upper gastrointestinal hemorrhage. Cases of mycotic hepatic artery aneurysm associated with streptococcal endocarditis have rarely been reported. In the present study, we report a case of massive hemobilia that was caused by ruptured mycotic hepatic artery aneurysm in a patient who was infected with streptococcal endocarditis 3 months previously. Transarterial embolization in the patient failed, possibly due to vascular variations. However, surgical treatment was successfully performed, and the patient completely recovered. In conclusion, surgical treatment may be useful in treating massive hemobilia under life-threatening conditions, even in cases of vascular variations and failure of transarterial embolization.

Hemobilia: Historical overview, clinical update, and current practices.

Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosis of hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.