Gangrena vesicular por colecistitis hemorrágica en paciente sin factores de riesgo: reporte de un caso

La colecistitis hemorrágica es una complicación rara de la colecistitis aguda, pero con alta mortalidad. Clínicamente es idéntica a la colecistitis aguda, y no suele presentarse con hemorragia gastrointestinal. Presentamos el caso de un varón 57 años, sin antecedentes, ni uso de anticoagulantes, referido a nuestro hospital por una "tumoración vesicular", tras los estudios tomográficos y de colangioresonancia, asociado a la caída de hemoglobina sérica, se define su sospecha. Ingresa a sala de operaciones y se evidencia una vesícula gangrenada, conteniendo coágulos y cálculos. Confirmando su diagnóstico con el estudio histopatológico. Debido a su similitud clínica, debe considerarse en pacientes con antecedentes de terapia anticoagulante, trauma, malignidad, o hallazgos compatibles con colecistitis alitiásica. Pero puede presentarse en pacientes sin antecedentes y estar asociado a colelitiasis. El diagnóstico temprano de esta complicación potencialmente fatal es importante para facilitar el manejo quirúrgico urgente, siendo el apoyo imagenológico, necesario para su sospecha.

Hemorrhagic cholecystitis is a rare complication of acute cholecystitis, but with high mortality. Clinically it is identical to acute cholecystitis, and it does not usually present with gastrointestinal bleeding. We present the case of a 57-year-old man, with no history or use of anticoagulants, referred to our hospital for a "gallbladder tumor", after tomographic and cholangioresonance studies, associated with a drop in serum hemoglobin, suspicion of him is defined. He enters the operating room and a gangrenous gallbladder is evident, containing clots and stones. Confirming his diagnosis with histopathological study. Due to its clinical similarity, it should be considered in patients with a history of anticoagulant therapy, trauma, malignancy, or findings consistent with acalculous cholecystitis. But it can occur in patients with no history and be associated with cholelithiasis. Early diagnosis of this potentially fatal complication is important to facilitate urgent surgical management, imaging support being necessary for its suspicion.

Colecistectomía de emergencia con diagnóstico intraoperatorio de hemobilia: reporte de un caso / Emergency cholecystectomy with an intraoperative hemobilia diagnosis: case report

RESUMEN La hemobilia (HB) es la presencia de sangre en o a través del tracto biliar. Las causas más comunes son iatrogénica, traumática, neoplasias y fístulas colangiovenosas o arteriobiliares. Y los cálculos biliares representan del 5-15 % de las causas. Presentamos el caso de una mujer 28 años, sin antecedentes, ni uso de anticoagulantes, diagnosticada inicialmente de colecistitis aguda, que requirió colecistectomía abierta de emergencia. Durante la operación se evidencia un coágulo adherido a la luz de la vesícula y dos cálculos. Confirmando el diagnóstico con los hallazgos histopatológicos. Debido a su similitud clínica, debe considerarse en pacientes con antecedentes de terapia anticoagulante, trauma, malignidad, o hallazgos compatibles con colecistitis alitiásica. Pero puede presentarse en pacientes sin antecedentes y estar asociado a colelitiasis. El tratamiento depende del estado hemodinámico y la etiología. Requiriendo cirugía en caso de colecistitis, ya que conlleva una alta tasa de mortalidad, y perforación vesicular (2-15 %).

ABSTRACT Hemobilia (HB) is the presence of blood in or through the biliary tract. Its most common causes are iatrogenic, traumatic, neoplasms, and cholangiovenous or arterio-biliary fistulas. Also, gallstones account for 5-15% of such cases. We present the case of a 28-year-old woman, with no remarkable history or anticoagulant use, who was initially diagnosed with acute cholecystitis, and required emergency open cholecystectomy. During the operation, a clot adhered to the gallbladder lumen and two calculi were evidenced. The diagnosis was confirmed with histopathological findings. Due to its clinical similarity, HB should be considered in patients with a history of anticoagulant therapy, trauma, malignancy, or with findings consistent with alithiasic cholecystitis. HB may also occur in patients with no remarkable history, and it be associated with cholelithiasis. Treatment depends on the patient's hemodynamic status and etiology. Surgery is required in cholecystitis, because of its high mortality rate and occurrence of gallbladder perforation (2-15%).

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.

Current status of clinical research on hematobilia / 临床肝胆病杂志

Hematobilia is one of the rare causes of upper gastrointestinal bleeding. It is difficult to diagnose in clinical practice, due to its atypical clinical manifestations, rare Quikle triad (abdominal pain, jaundice, and upper gastrointestinal bleeding), and a lack of specificity. At present, it is believed that iatrogenic injury is the main cause of hematobilia, selective hepatic arteriography is the preferred choice for the diagnosis of hematobilia, and interventional embolization is the main treatment method. With reference to related articles, this article mainly elaborates on the current status of the research on the etiology, clinical manifestations, diagnosis, and treatment of hematobilia.

Risk of bleeding complications in percutaneous biliary drainage: the paradox of the normal hemostasis / Risco de complicações de sangramento na drenagem biliar percutânea: o paradoxo da hemostase normal

ABSTRACT Background: Percutaneous biliary drainage is a safe procedure. The risk of bleeding complications is acceptable. Frequently, patients with biliary obstructions usually have coagulation disorders thus increasing risk of bleeding. For this reason, patients should always fit the parameters of hemostasis. Aim: To determine whether the percentage of bleeding complications in percutaneous biliary drainage is greater in adults with corrected hemostasis prior to the procedure regarding those who did not require any. Methods : Prospective, observational, transversal, comparative by independent samples (unpaired comparison). Eighty-two patients with percutaneous biliary drainage were included. The average age was 64±16 years (20-92) being 38 male and 44 female. Patients who presented altered hemostasis were corrected and the presence of bleeding complications was evaluated with laboratory and ultrasound. Results: Of 82 patients, 23 needed correction of hemostasis. The approaches performed were: 41 right, 30 left and 11 bilateral. The amount of punctures on average was 3±2. There were 13 (15.8%) bleeding complications, 12 (20%) in uncorrected and only one (4.34%) in the corrected group with no statistical difference. There were no differences in side, number of punctures and type of drainage, but number of passes and the size of drainage on the right side were different. There was no related mortality. Conclusion: Bleeding complications in patients requiring hemostasis correction for a percutaneous biliary drainage was not greater than in those who did not require any.

RESUMO Racional: A drenagem biliar percutânea é procedimento seguro. O risco de complicações hemorrágicas é aceitável. Frequentemente, os pacientes com obstruções biliares apresentam distúrbios de coagulação, aumentando o risco de sangramento. Por esse motivo, eles devem sempre ser adequados aos parâmetros da hemostasia. Objetivo: Determinar se a porcentagem de complicações hemorrágicas na drenagem biliar percutânea é maior em adultos com hemostasia corrigida antes do procedimento em relação àqueles que necessitaram nenhuma. Métodos: Estudo prospectivo, observacional, transversal, comparativo por amostras independentes (comparação não pareada). Oitenta e dois pacientes foram submetidos à drenagem biliar percutânea. A idade média foi de 64±16 anos (20-92), 38 eram homens e 44 mulheres. Os pacientes que apresentaram hemostasia alterada foram corrigidos, e a presença de complicações hemorrágicas foi avaliada com exames laboratoriais e ultrassonográficos. Resultados: Dos 82 pacientes, 23 necessitaram de correção da hemostasia. O acesso à direita foi em 41 casos, 30 à esquerda e 11 bilaterais. A quantidade de punções em média foi de 3±2. Houve 13 (15,8%) complicações hemorrágicas, 12 (20%) no grupo não corrigido e apenas uma (4,34%) no corrigido sem diferença estatística. Não houve diferenças no lado, no número de perfurações e no tipo de drenagem, mas o número de passagens e o tamanho da drenagem no lado direito foram diferentes. Não houve mortalidade. Conclusão: As complicações hemorrágicas em pacientes que necessitam de correção da hemostasia antes da drenagem biliar percutânea não são maiores do que naqueles que não a requerem.

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.

Interventional therapy on hemobilia induced by hepatic artery pseudoaneurysm / 实用放射学杂志

Objective To investigate the safety and feasibility of the interventional therapy on hemobilia induced by hepatic artery pseudoaneurysm(PsAn).Methods The clinical data of 28 patients with hemobilia in our department was analyzed retrospectively.All the patients were firstly treated with internal medicine,and then treated by interventional therapy.The angiography clearly displayed the shape,size and location of the PsAn,and superselective embolism was performed during the operation.The symptomatic treatment and the bile duct drainage were performed after operation.Postoperative follow-up time was 1-3 6 months,and the follow-up endpoint was the death of patient.Results 28 patients were diagnosed as hepatic artery PsAn.The interventional embolization therapy on hemobilia was completely effective.A total of 110 spring coils were applicated in the study,there was no complication related to interventional therapy.One patient with hilar cholangiocarcinoma was dead due to infection and liver failure after four weeks of operation.Two patients with choledochal carcinoma died of tumor progression after 11.5 and 14.2 months of interventional therapy,respectively.In addition,2 patients with gastric carcinoma died of tumor progression after 4 and 6.5 months of operation,respectively,and 1 patient with common bile duct stones who underwent laparoscopic surgery died of complications of coronary heart disease after 5 months of interventional therapy. The other patients all had satisfactory therapeutic effect and recovered well.Conclusion The interventional therapy has definite therapeutic effect on hemobilia induced by hepatic artery PsAn.The technique is worthy of popularized clinically due to its features of simplicity,safety and reliablity.

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.

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.

Right hepatic artery aneurysm / Aneurisma de artéria hepática direita

ABSTRACT We report a case of an aneurysm of the right hepatic artery and its multidisciplinary management by general surgery, endoscopy and radiology services. Being a case of extremely low incidence, it is important to show its diagnostic and therapeutic approach.

RESUMO Relatamos um caso de aneurisma da artéria hepática direita conduzido de forma multidisciplinar pelos Serviços de Cirurgia Geral, Endoscopia e Radiologia. Em se tratando de caso de incidência baixíssima, é importante mostrar o enfoque diagnóstico e terapêutico usado em seu manejo.

Preventive measures for bile duct injury and bleeding during laparoscopic cholecystectomy / 临床肝胆病杂志

ObjectiveTo investigate the surgical methods for the prevention of bile duct injury and bleeding during laparoscopic cholecystectomy (LC). MethodsThe clinical data of 600 patients who underwent LC from September 2010 to June 2013 were analyzed retrospectively, and with reference to related articles and data, the methods for the prevention of bile duct injury and bleeding were summarized. ResultsAmong the 600 patients, 2 were converted to open surgery and 1 experienced biliary fistula after LC. There were no long-term complications, and all the patients were cured and discharged, without deaths. ConclusionThe key points in preventing bile duct injury and bleeding during LC are the attention to blunt dissection and fine anatomy of the Calot′s triangle, the emphasis on the separation and identification of the three-dimensional structure of the neck of the gallbladder, a flexible and proper treatment of the anatomic structures of the bile duct in patients with acute or subacute cholecystitis, and a decision on the resection or preservation of the gallbladder wall, which is made according to the situation during surgery.

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.

Hemobilia secundaria a pseudoaneurisma roto: reporte de caso / Hemobilia secondary to a broken pseudoaneurysm: case report

Se presenta un caso de paciente con dolor abdominal asociado a ictericia y hemorragia digestiva alta (hematoquezia, melena) causado por hemobilia secundaria a ruptura de pseudoaneurisma de una rama de la arteria hepática derecha. El diagnóstico se realizó por medio de endoscopía digestiva alta, realizando arteriografía con embolización selectiva cesando el sangrado.

A patient presents with abdominal pain associated with jaundice and upper gastrointestinal bleeding (hematochezia, melena) caused by hemobilia secondary to rupture of pseudoaneurysm of a branch of the right hepatic artery. The diagnosis was made by upper endoscopy, performing arteriography with selective embolization ceased bleeding.

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.

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.

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.

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.

Hemobilia após trauma abdominal: relato de 3 casos / Hemobilia after abdominal trauma: report of 3 cases

Hemobilia é rara e potencialmente fatal. A suspeita de sangramento em trato biliar é maior em casos recentes de trauma hepático ou cirurgia hepatobiliar. Ruptura de pseudoaneurisma de artéria hepática é causa comum de hemobilia. Relatamos 3 casos de hemobilia em indivíduos jovens, acometidos por trauma abdominal, que evoluíram com ruptura de pseudoaneurisma e necessidade de embolização angiográfica de vaso sangrante.

Hemobilia is rare and potentially fatal. Suspect bleeding in the biliary tract is higher in recent cases of liver trauma or hepatobiliary surgery. Rupture of hepatic artery pseudoaneurysm is a common cause of hemobilia. We report 3 cases of hemobilia in young individuals suffering from abdominal trauma, who developed pseudoaneurysm rupture and need for angiographic embolization of bleeding vessel.