HemobiliaHemobiliaDr. Wong Po Yan, SabrinaPrincess Margaret Hospital

Hemobilia…

• Case scenario• Etiology• Investigations• Management

• Past health: chronic rheumatic heart disease on warfarin• Admitted for epigastric pain• CT• ERCP• Repeat CT• Angiogram• Repeat ERCP

Cholangiocarcinoma

Hilar mass

Hemobilia

49 year old lady

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Etiology

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Iatrogenic Trauma Gallstones Malignancy Inflammation Vascular

Sandblom 1972

Curet 1984

Yoshida 1987

Green 2001

Devakumar 2014

Abnormal communication between blood vessels and bile duct

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e

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Etiology

Iatrogenic traumaIatrogenic trauma

• Percutaneous hepatic procedures› Liver biopsy (0.06 – 1%)

› PTBD, PTC (2 – 10%)

• Cholecystectomy

› Hepatic artery pseudoaneurysm

› Cystic artery stump pseudoaneurysm

• Instrumentation

› Metallic stents (0.5% endoscopic, 1.6% percutaneous)

› Plastic stents

• Other case reports: T-tube, RFA, lithotripsy, ECBD Haemobilia. BJS. 2001

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Etiology

TraumaTrauma

• Acute / delayed presentation (more common)

• Penetrating / blunt injury

• Grade of liver injury ≠ Degree of hemobilia

• Associated factors:› Cavitations

› Infection

› Initial operation: packing, deep mattress sutures

Hemobilia after penetrating and blunt liver injury: treatment with selective hepatic artery embolization. Injury. 2004

↓ Liver healing

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Etiology

Quinke’s triad:

Cholestasis

Blood clots

Onset – days to weeks

Haemobilia. BJS. 2001Hemobilia: endoscopic, fluoroscopic and cholangioscopic diagnosis. Hepatology . 2010

(Slow bleeding)

CholangitisPancreatitisCholecystitis

Investigation

ProcedureProcedure FindingsFindings

OGD To exclude other sources of UGIB

Ultrasound Biliary obstructionCholecystitisPseudoaneurysm (with Doppler)

CT PseudoaneurysmAssociated injuryDisease status

ERCP Blood clots as filling defectsIndentation by pseudoaneurysm

Angiogram Contrast extravasationPseudoaneurysm

High index of suspicionHigh index of suspicion

Therapeutic

Management

Procedure

Liver biopsy Tract embolization

PTBD Avoid insertion near liver hilum

Cholecystectomy Avoid injury to hepatic arteries bye.g. diathermy, suture, clipsMinimize infection, biloma

PreventionPrevention

Patient’s own risk

Ascites Drainage

Coagulopathy Replacement of clotting factors, vitamin K1, withhold anti-platelet agents

Is the procedure really indicated?

Management

PrinciplePrinciple

1. Stop the bleeding

2.Drain the biliary obstruction

Initial managementInitial management

1. Resuscitation

2.Control sepsis

Angiogram +/-

Transarterial embolization

ERCP

Management

Transarterial Embolization (TAE)Transarterial Embolization (TAE)

• Diagnostic rate >90%

• Success rate 80 – 100%

• Pre-requisite:› Patent portal vein

› Patent hepatic artery

• Celiac axis angiogram

• Superior mesenteric angiogram

• Selective embolization

Management

Angiographic management of massive hemobilia due to iatrogenic trauma. Gastrointestinal Radiology. 1991Selective surgical indications in iatrogenic hemobilia. Surgery. 1997Evaluation of selective hepatic angiography and embolization in patients with massive hemobilia. Hepatobiliary and Pancreatic Dis Int. 2005Transcatheter embolization in management of hemobilia. Abdom Imaging. 2006Transcatheter arterial coil embolization of iatrogenic pseudoaneurysms after hepatobiliary and pancreatic interventions. Hepatogastroenterology. 2007Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of literature. Eur J Gastroenterol Hepatol. 2012

Case series No.

Cause Success Failure

Okasaki 1991 10 Iatrogenic 100% /

Belghiti 1997 19 Iatrogenic 87% 7 underwent surgery:- 3 techinical failure- 3 hemocholecystitis- 1 ischemic cholecystitis

Xu 2005 16 Mixed 75% 2 re-bleeding → 2nd TAE2 technical failure and died

Srivastava 2006 32 Mixed 75 % 8 underwent surgery3 re-bleeding → 2nd TAE

Tsai 2007 20 Iatrogenic 85% 3 underwent surgery:- 2 technical failure- 1 re-bleeding, failed 2nd TAE

Marynissen2012 12 Iatrogenic 100% /

Management

Transarterial Embolization (TAE)Transarterial Embolization (TAE)

Post-cholecystectomy hemobilia Cystic artery stump pseudoaneurysm:Coil embolization of right hepatic artery

Hemobilia after lapaporoscopic cholecystectomy. Int Surg. 2012

Management

Transarterial Embolization (TAE)Transarterial Embolization (TAE)

RPC, ERCP multiple CBD stones

Quinke’s triadERCP

Readmitted for tarry stoolOGDAngiogram + embolization

Management

Transarterial Embolization (TAE)Transarterial Embolization (TAE)

Metallic stents for malignant biliary obstructionAll successful TAE with no re-bleeding

Reports E P Mean onset Stent type

Monroe 1993 1 3 weeks Uncovered Wallstent

Murayama 1997 1 1 month Uncovered Wallstent

Rai 2003 1 1 year Unknown

Watanabe 2012 1 9 months Uncovered Wallflex

Hyun 2013 3 3 11 weeks Various

Yasuko 2014 2 3 months Uncovered Wallflex

E = endoscopically placed stent P = percutaneously placed stent

Pseudoaneurysm caused by self-expandable metal stents: a report of three cases. Endoscopy. 2014

Management

Endoscopic managementEndoscopic management

• Sphincterotomy

• Removal of blood clots

• Insertion of plastic stent

• Placement of nasobiliary drain:

› Irrigation

› Monitoring of bleeding

› Cholangiogram

Endoscopic management of traumatic hemobilia. Journal of Trauma. 2007Etiology, clinical features and endoscopic management of hemobilia: a retrospective analysis of 37 cases. Korean J Gastroenterol. 2012

To relieve biliary obstructionTo drain bile leak

Management

Endoscopic managementEndoscopic management

• 37 patients:

› 28 malignancy

› 8 inflammation

• ERCP:

› 2 Sphincterotomy only

› 26 Endoscopic nasobiliary drainage

› 7 Endoscopic retrograde biliary drainage

• Results:› Hemobilia successfully treated in nasobiliary drainage

Etiology, clinical features and endoscopic management of hemobilia: a retrospective analysis of 37 cases. Korean J Gastroenterol. 2012

90% Jaundice

Management

SurgerySurgery

Indications:

• When TAE fails

• When endoscopic or percutaneous decompression fails

• Hemodynamic instability

• Laparotomy for other reasons:

› Cholecystitis

› Resectable neoplasm

Management

SurgerySurgery

• Ligation of bleeding vessel

• Pseudoaneurysm excision

• Hepatic artery ligation (non-selective)

• Partial hepatic resection

• Exploration of CBD

Conclusion

• Iatrogenic trauma is the most common cause

• Diagnosis requires high index of suspicion

• Transarterial embolization in massive hemobilia

• Endoscopic biliary decompression is important

• Surgery is the last resort

Management

Other developmentOther development

• USG guided percutaneous thrombin injection for pseudoaneurysm

Cystic artery pseudoaneurysm presenting as a complication of laparoscopic cholecystectomy treated with percutaneous thrombin injection. Clinical Imaging. 2014

Investigation

UltrasoundUltrasound• Hyper-echoic blood may be confused as stones

• Iso-echoic clot, the bile ducts may not be visualized

• Sensitivity varies widely 40 – 90%

Haemobilia. BJS. 2001Massive haemobilia: a diagnostic and therapeutic challenge. World J Surg. 2014

CTACTA• Detect hemorrhage 0.5ml/min (vs. 0.35ml/min in angiogram)

Investigation

Bleeding from PTBD – Tractogram / Cholangiogram

Absent central bile duct sign Absent central bile duct sign Transgression of portal vein Transgression of portal vein

Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Techniques in vascular and interventional radiology. 2008

Management

Transarterial Embolization (TAE)Transarterial Embolization (TAE)

Low morbidity• Post-embolization syndrome

• Hepatic necrosis

• Liver abscess

• Re-bleeding

• Non-target embolization

• Ischemic cholecystitis, pancreatitis

• Catheter-induced damage of arteries

• Access site morbidity

• Contrast morbidity

Transcatheter arterial embolization in the management of hemobilia. Abd Imaging. 2006

Management

EvolutionEvolution

Management

Transarterial Embolization (TAE)Transarterial Embolization (TAE)

Previous PTBD for CA pancreas (3 weeks after Whipple operation):Coil embolization of branch of right hepatic artery

Hepatobiliary and pancreatic: iatrogenic hemobilia. J Gastroenterol Hepatol. 2008

Management

Transarterial Embolization (TAE)Transarterial Embolization (TAE)

Bleeding from PTBD

Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Techniques in vascular and interventional radiology. 2008

Celiac axis

SMA

Hemobilia from PTBD

Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Techniques in vascular and interventional radiology. 2008

Is patient stable?

No

Yes

Massive Hemobilia

Massive haemobilia: a diagnostic and therapeutic challenge. World J Surg. 2014

Tract embolization in liver biopsy

Indications:Indications:• Coagulopathy: INR> 1.5, platelet <20000, von Willebrand disease• Active oozing from needle tract• Chronic renal failure• Hypertension (SBP >160, DBP > 100, MBP > 120)

Embolizing agents:Embolizing agents:• gelfoam, coils, N-butyl cyanoacrylate

Technique:Technique:• Use introducer in biopsies (co-axial system)• Exchange catheter with vascular sheath in drainage procedure

Techniques in intervention radiology. 2010Ultrasound-guided plugged percutaneous biopsy of solid organs in patients with bleeding tendencies. HKMJ. 2014

Hemobilia after cholecystectomy

Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of literature. Eur J Gastroenterol Hepatol. 2012

Pseudoaneurysm caused by self-expandable metall stents: a report of three cases. Endoscopy. 2014

Hemobilia after metallic stents

Risk factors: chemotherapy, irradiationMechanism for pseudoaneurysm formation:• Direct trauma to nearby vessels• Chronic inflammation & fibrosis• Pressure exerted onto tumor

Wallstent vs. Wallflex

Pseudoaneurysm caused by self-expandable metall stents: a report of three cases. Endoscopy. 2014

Hemobilia after metallic stents