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From Hemobilia to Hematochezia
•A 49-year-old woman
•transferred from an outside hospital because of severe hematochezia with a drop in hemoglobin from 14 to 8.3 g/dl.
• She initially presented because of a sudden onset of intense and constant sharp pain in the epigastric area that started soon after food intake.
• Two months prior to her hospitalization she underwent a laparoscopic cholecystectomy for recurrent abdominal pain.
• Her surgery and initial recovery was uneventful
• although she occasionally experienced brief episodes of epigastric pain that were less intense and never lasted longer than 30 min.
prior medical history
• Her prior medical history was otherwise only remarkable for a quiescent ulcerative colitis.
physical examination
• The main findings on physical examination were icteric sclerae
• and mild skin icterus
• as well as dark blood in the rectal ampulla.
laboratory tests
• demonstrated a moderate elevation of her bilirubin with 4.7 mg/dl (direct bilirubin: 4.5 mg/dl)
• liver enzymes with alkaline phosphatase of 127 U/l,
• AST 197 U/l
• ALT 469 U/l.
ultrasound examination
To further delineate the underlying problem an ultrasound examination was performed
• which demonstrated a fluid collection in the gallbladder fossa
• and a dilation of the intra- and extrahepatic biliary tree .
endoscopy
• An initial endoscopy with antegrade scope did not reveal a bleeding site in the proximal GI tract.
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side-viewing endoscope
a prominent papilla was seen with the side-viewing endoscope.
• Upon intubation of the papilla, a significant amount of blood drained from the bile duct .
• Contrast injection into the common bile duct demonstrated blood clots .
angiogram
• An angiogram showed a large aneurysm of the right hepatic artery with penetration and bleeding into the biliary tree .
Diagnosis
• The combination of abdominal pain, bleeding and icterus after cholecystectomy pointed at problems in the biliary tree.
• Based on these findings, the patient underwent embolization of the feeding artery, which achieved hemostasis .
Discussion:
Hemobilia is defined as blood in the biliary tree
• which can manifest as melena,
• hematochezia,
• and hematemesis or as a gradual blood loss associated with biliary colic and/or jaundice.
• Only about 5 % of the patients with hemobilia present with all three signs and symptoms.
Etiology
• Etiology may be trauma,
• most often iatrogenic (50% in Western countries),
• infection (more common in 3rd World),
• malignancy,
• chronic inflammatory disorders, or gallstones.
• The combination of acute biliary symptoms, jaundice and gastrointestinal bleeding should raise the suspicion for hemobilia,
• especially if the patient had recently undergone a liver biopsy (typically less than 5 days prior to presentation), a cholecystectomy or any surgical or endoscopic manipulations of the biliary system (up to 3-5 weeks prior to presentation).
• The diagnosis of hemobilia can be made endoscopically when bleeding from the ampulla is seen.
• Ultrasound and /or CAT scan may show intrahepatic fluid collections and / or ductal dilation.
• Scintigraphy with labeled erythrocytes may suggest hemobilia and trigger the next step,
• angiography that typically is diagnostic.
treatment
• In the past, treatment for hemobilia has mostly been surgical, frequently requiring a partial hepatectomy if the liver is source of bleeding.
• Alternatively, hepatic ligation has been performed successfully. Based on the results of hepatic artery ligation, angiographic embolization has been tried with success rates exceeding 80 %, making it the initial treatment of choice in most patients.
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