Acute hemorrhagic cholecystitis as a rare cause of hemobilia.

Hemobilia is an unusual type of gastrointestinal bleeding most frequently due to iatrogenic injury, trauma, or neoplasia. Acute cholecystitis as a cause of hemobilia is rare. We present the case study of a patient with bleeding from eroded gallbladder mucosa in the setting of severe calculous cholecystitis. The hemorrhagic episode was preceded by acute ERCP due to obstructive icterus with extraction of the calculi, followed by the development of severe acute pancreatitis. These factors initially misled the diagnosis. The bleeding was not hemodynamically important and routine diagnostic methods did not reveal its exact source. Direct choledochoscopy (SpyGlassTM) proved to be helpful in determining the right diagnosis, as it ruled out any injury or tumor in the main bile ducts and considerably supported the assumption of intrabladder bleeding. Surgical revision confirmed the cause, and subsequent cholecystectomy solved the whole problem.

Haemobilia: secondary to micro aneurysms of hepatic artery.

Hepatic artery is the fourth most common site of the intraabdominal aneurysm, after infra renal aorta, iliac artery and splenic artery aneurysms. Rupture of the aneurysm may lead to the upper gastrointestinal haemorrhage. Here we report a 5 years old boy, who presented with fever, abdominal distension and unexplained upper GI bleed. Upper GI endoscopy revealed a normal esophagus and stomach with clear evidence of haemobilia with blood oozing from the ampulla. Fluoro- guided angiography followed by embolization of hepatic artery branches with 5 metallic coils was performed in this case by an interventional radiologist.

[A case of hemobilia due to the rupture of pancreaticoduodenal artery aneurysm with choledocholithiasis].

A 79-year-old male patient had a huge choledocholithiasis that was difficult to remove and underwent endoscopic retrograde biliary drainage. He complained of hematemesis upon admission to our hospital. Endoscopic retrograde cholangiography showed bleeding from the papilla of Vater and revealed an upper filling defect with a large stone in the common bile duct. Furthermore, computed tomography detected an aneurysm close to the stone. Considering the occurrence of a ruptured pancreaticoduodenal artery aneurysm, we diagnosed this condition as hemobilia. Through angiography, we also detected a saccular aneurysm in the posterior superior pancreaticoduodenal artery (PSPDA);subsequently, selective transcatheter arterial embolization (TAE) was performed. However, bleeding persisted after TAE;therefore, we performed second-time embolization for other PSPDA branches. Consequently, hemostasis was achieved. To date, bleeding has not reoccurred. The pancreaticoduodenal artery constitutes a complex arcade;hence, cases of extremely difficult hemostasis by embolization have been reported. Herein, we have presented a life-saving case of choledocholithiasis treated with TAE for biliary bleeding from a PSPDA aneurysm rupture.

[Hemobilia caused by hepatic artery pseudoaneurysm after endoscopic biliary stenting for malignant hilar biliary strictures:a case report].

A 78-year-old female presented at our hospital with hilar biliary strictures caused by gallbladder cancer. Metal stents with a dilated diameter of 8mm were placed in a side-by-side fashion in the left and right hepatic ducts. However, 3 months after stenting, the patient experienced a sudden onset of hematemesis. Emergent enhanced abdominal angiography revealed a right hepatic arterial pseudoaneurysm that had likely ruptured, thus causing the hemobilia. Probable association of biliary stents with pseudoaneurysm was also demonstrated. Selective angiography revealed bleeding from the pseudoaneurysm into the biliary stents, which was controlled by coil embolization. The patient was subsequently discharged on hospital day 15.

[A case of a hepatic arterial pseudoaneurysm that occurred after acute cholangitis due to choledocholithiasis].

We describe a 52-year-old male who underwent endoscopic retrograde biliary drainage for acute cholangitis associated with common bile duct stones. Endoscopic papillary balloon dilatation was performed, and the stones were removed using a balloon catheter. Simultaneously, we initiated edoxaban for portal vein thrombosis. Approximately one month later, he visited our hospital complaining of tarry stools and dizziness. Contrast-enhanced computed tomography revealed a pseudoaneurysm in the hepatic artery (A7), and he was diagnosed with hemobilia from bile duct perforation associated with the hepatic arterial pseudoaneurysm. We performed an emergent transcatheter arterial embolization. Notably, re-bleeding has not occurred to date. Hepatic arterial pseudoaneurysms can occur after acute cholangitis;therefore, careful follow-up is essential.

Haemobilia - A Rare Cause of Upper Gastro-Intestinal Bleeding.

Haemobilia is a rare cause of upper gastrointestinal bleeding that consists of haemorrhage within the biliary tree. Most cases of haemobilia are due to iatrogenic cause, laparoscopic or open cholecystectomy, abdominal trauma, gallstones, hepatic tumours, vascular aneurism. We present the case of a male patient admitted in the surgery department for epigastric and right hypochondria pain, nausea and vomiting. Open cholecystectomy was performed with a trans-cystic tube drainage. Postoperative outcome was favourable but with a continuous decrease in haemoglobin level. In the 13th day postoperatively biliary drainage was 800 ml - haemobilia. Patient health status altered and melena and hematemesis occurred. Endoscopy, cholangiography and abdominal computer tomography (CT) were performed. The episode repeated in day 27 after initial surgery. Duodenotomy and exploration of the biliary tree was performed. Angiography was performed next day that revealed biliary-arterial fistula within segment IV of the liver followed by embolization. Haemobilia reoccurred fifteen days later and colonoscopy and angiography were performed. Embolization with metallic coils was performed. Patient outcome was favourable and was discharged 13 days after second embolization. Interventional angiography remains the first treatment option of haemobilia. Selective arterial ligation or hepatectomy remain the options in case of lack of angiography or insufficient results after embolization.

Diffusion-weighted magnetic resonance imaging for non-neoplastic conditions in the hepatobiliary and pancreatic regions: pearls and potential pitfalls in imaging interpretation.

Potentially, diffusion-weighted magnetic resonance imaging (DWI) can assess the functional information on concerning the status of tissue cellularity, because increased cellularity is associated with impeded diffusion. DWI in the hepatobiliary and pancreatic regions has demonstrated the usefulness to detect malignant lesions and differentiate them from benign lesions. However, it has been shown more recently that there is some overlap in ADC values for benign and malignant neoplasms. Moreover, some non-neoplastic lesions in the hepatobiliary and pancreatic regions exhibit restricted diffusion on DWI, because of pus, inflammation, or high cellularity. Focal eosinophilic liver disease, hepatic inflammatory myofibroblastic tumor, granulomatous liver disease, acute cholecystitis, xanthogranulomatous cholecystitis, focal pancreatitis, or autoimmune pancreatitis frequently exhibit restricted diffusion on DWI, which may be confused with malignancy in the hepatobiliary and pancreatic regions. Thus, DWI should not be interpreted in isolation, but in conjunction with other conventional images, to avoid the diagnostic pitfalls of DWI. Nevertheless, the presence of diffusion restriction in the non-neoplastic lesions sometimes provides additional information regarding the diagnosis, in problematic patients where conventional images have yielded equivocal findings. DWI may help differentiate hepatic abscess from malignant necrotic tumors, gallbladder empyema from dense bile or sludge in the gallbladder, and pylephlebitis from bland thrombosis in the portal vein. Therefore, knowledge of DWI findings to conventional imaging findings of diffusion-restricted non-neoplastic conditions in the hepatobiliary and pancreatic regions helps establishing a correct diagnosis.

Minimally invasive image-guided interventional management of Haemobilia.

Hemobilia is a well known cause for upper gastrointestinal (UGI) bleed seen commonly in setting of iatrogenic or accidental trauma and various inflammatory and neoplastic conditions. Patients present with UGI bleed and symptoms of associated biliary obstruction. Management options in intractable cases are surgery and endovascular embolisation. We report a series of eighteen patients presented with severe hemobilia from January 2010 to October 2014, who were managed by endovascular approach in our department. Etiology in these patients were trauma (n = 3), liver biopsy (n = 3), surgery (n = 3), percutaneous procedures (n = 2), inflammatory (n-3), neoplasm (n = 1) and the rest were idiopathic. Angiography revealed pseudoaneurysms of hepatic artery (n = 5), splenic artery (n = 1) and gastroduodenal artery (n = 1) and arterio-biliary fistula (n = 1). Embolising agents used were detachable coils (n = 10) and glue (n = 8). All patients had technical and clinical success with minor non-consequential complications. Our findings show that endovascular embolisation is a simple, safe, accurate and effective treatment in patients with severe hemobilia. It is a viable alternative to major and potentially morbid surgeries.

[Hemobilia secondary to hepatic artery pseudoaneurysm]. / Hemobilia secundaria a pseudoaneurisma de la arteria hepática.

Hemobilia is defined as the presence of blood in the biliary tree characterized by the triad: jaundice, right hypochondrium pain (RH) and upper gastrointestinal bleeding (UGB). Among the etiologies highlighted in order of frequency there are: liver trauma (accidental and iatrogenic), inflammatory causes (acute and chronic cholecystitis), infections (cholangitis, liver abscesses, parasitic infections) and vascular diseases (aneurysms, vasculitis, arteriovenous malformations). There exist many complementary tests for the diagnosis of hemobilia, such as imaging (abdominal ultrasound, CT scan, angio CT), videoendoscopy, endoscopic retrograde cholangiopancreatography and angiography, the latter being considered the diagnostic tool and therapeutic modality of choice. We report the case of a 52-year-old male patient with hemobilia secondary to apseudoaneurysm ofthe hepatic artery, along with a review of the existing literature.

Massive hemobilia: a diagnostic and therapeutic challenge.

BACKGROUND: Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. In this retrospective analysis, we have evaluated the challenges involved in the diagnosis and management of massive hemobilia. METHODS: Between 2001 and 2011, a total of 20 consecutive patients (14 males) who were treated in our department for massive hemobilia were included in the study and their records were retrospectively analyzed. RESULTS: Causes of hemobilia were blunt liver trauma (n = 9), hepatobiliary intervention (n = 4), post-laparoscopic cholecystectomy hepatic artery pseudoaneurysm (n = 3), hepatobiliary tumors (n = 3), and vascular malformation (n = 1). Melena, abdominal pain, hematemesis, and jaundice were the leading symptoms. All patients had undergone upper GI endoscopy, abdominal ultrasound, and computerized tomography of the abdomen. An angiogram and therapeutic embolization were done in 12 patients and was successful in nine but failed in three, requiring surgery. Surgical procedures performed were right hepatectomy (n = 4), extended right hepatectomy (n = 1), segmentectomy (n = 1), extended cholecystectomy (n = 1), repair of the pseudoaneurysm (n = 3), and right hepatic artery ligation (n = 1). CONCLUSION: The successful diagnosis of hemobilia depends on a high index of suspicion for patients with upper GI bleeding and biliary symptoms. Although transarterial embolization is the therapeutic option of choice for massive hemobilia, surgery has a definitive role in patients with hemodynamic instability, after failed embolization, and in patients requiring laparotomy for other reasons.

Hemobilia associated with a giant thrombosed aneurysm of the hepatic artery requiring hepatectomy.

Hemobilia is an unusual and potentially catastrophic cause of gastrointestinal bleeding. Although hepatic artery aneurysm is a cause of hemobilia, nontraumatic cases are infrequently reported. Herein, we describe the case of a giant hepatic artery aneurysm requiring hepatectomy because of repeated hemobilia in a patient with Marfan syndrome. A 53-year-old man presented to our hospital with sudden epigastric pain and jaundice. Abdominal computed tomography showed a giant hepatic arterial aneurysm in the porta hepatis, and emergency endoscopic retrograde cholangiography revealed hemobilia. Assuming that the aneurysm caused the hemobilia, we performed an abdominal angiogram for treatment. The study revealed a thrombosed aneurysm along with tortuous abnormal vessels in the periphery of the left hepatic artery, which appeared to surround the aneurysm. Therefore, we embolized the left hepatic artery, and immediate hemostasis was achieved. Rebleeding occurred 3 times thereafter, and each time, transarterial embolization was performed, resulting in prompt but only temporary hemostasis. Then, emergency left hemihepatectomy and resection of the aneurysm were performed. Pathologic examination of the resected specimen revealed that the aneurysm was completely thrombosed and organized; however, abnormal arterioles proliferated between the aneurysmal wall and the bile duct. The unique feature of this case was that the abnormal arterioles induced by the organized hepatic artery aneurysm, not the aneurysm itself, caused the hemobilia.

Delayed Post-Traumatic Hemobilia in a Patient With Blunt Abdominal Trauma: A Case Report and Review of the Literature.

Hemobilia is a rare condition defined as bleeding in the biliary tract. The clinical presentation is variable. The typical manifestation consists of jaundice, upper gastrointestinal bleeding, and right upper quadrant abdominal pain. This set of symptoms is known as "Quincke's triad." It is present in only 22%-35% of cases. Post-traumatic hemobilia is an extraordinarily rare condition occurring in only 6% of the patients with hemobilia. In general, it occurs in less than 0.2% of patients with liver trauma. A delay in the development of bleeding after liver trauma is frequent. Early diagnosis is essential because massive bleeding into the biliary tract is a potentially life-threatening condition. We present a case of a patient with massive hemobilia developed 12 days after blunt abdominal trauma. Computed tomography angiography showed two pseudoaneurysms in hepatic segments V and VIII with contrast medium extravasation. We successfully performed digital subtraction angiography with selective transcatheter arterial embolization of the leaking segment VIII pseudoaneurysm. Embolization of the pseudoaneurysm in segment V was technically impracticable. Our article provides a review of the published literature focussing on the prevalence, diagnostics, and treatment of post-traumatic hemobilia.

Two distinct episodes of life-threatening hemobilia due to a lesion of common bile duct and delayed intrapancreatic arteriobiliary fistula managed by emergency pancreatoduodenal resection.

Hemobilia is an extremely rare cause of upper gastrointestinal bleeding. It often has intermittent manifestation, which may lead to significant diagnostic delay. In 65% of the cases, the causes are iatrogenic, in 7% the cause is malignancy, in 5% - gallstones, in 8% it is inflammation (cholecystitis, parasites, reflux cholangitis), vascular abnormality is the cause in 7% (most commonly pseudoaneurysm of the hepatic artery), and pancreatic pseudocyst causes hemobilia in 1%. In almost all cases, the bleeding originates from intrahepatic or extrahepatic bile ducts, and rarely from the pancreas.

Pseudoaneurysm of the hepatic artery and hemobilia: a rare complication of laparoscopic cholecystectomy; clinical case and literature review.

Laparoscopic cholecystectomy is the Gold Standard for the treatment of symptomatic cholelithiasis. There is still an increase in the rate of incidence of biliary and vascular injuries with laparoscopy. Hepatic artery pseudoaneurysm is a rare but serious complication associated with laparoscopic cholecystectomy and bile duct injury. The diagnosis may be difficult. Our experience of a case of iatrogenic lesion of the right hepatic artery with the formation of pseudoaneurysm treated by means of embolization of the artery is presented here.

Inflammatory and noninflammatory vascular disease causing hemobilia.

Typical angiographic finding of polyarteritis nodosa (PAN) shows aneurysms in small- and medium-size arteries, which can assist in diagnosis. Mimics of vasculitis share similar angiographic and clinical manifestations with PAN, making diagnosis confusing. We report 2 patients admitted with hemobilia, one of whom had vasculitis and case of the other mimicked vasculitis.The first patient was an 18-year-old man with epigastric pain. On serial workup, hemobilia with multiple hepatic artery aneurysms was diagnosed and embolized. Later, PAN was confirmed on pathologic examination of gallbladder after cholecystectomy.Second patient was an 18-year-old woman also with epigastric pain. Serial workup revealed multiple microaneurysms of the hepatic artery without bleeding, but 4 days later, fistula between hepatic artery and bile duct was found, and embolization was performed. She was readmitted 1 month later because of hemorrhage of gallbladder, and pathologic examination of gallbladder showed evidence of fibromuscular dysplasia.Clinicians should be aware of mimics of vasculitis when diagnosing gastrointestinal involvement of vasculitis.

A case of hemocholecyst associated with hemobilia following radiofrequency ablation therapy for hepatocellular carcinoma.

Radiofrequency ablation (RFA) is performed as an alternative to surgical resection for primary or secondary liver malignancies. Although RFA can be performed safely in most patients, early and late complications related to mechanical or thermal damage occur in 8-9.5% cases. Hemocholecyst, which refers to hemorrhage of the gallbladder, has been reported with primary gallbladder disease or as a secondary event associated with hemobilia. Hemobilia, defined as hemorrhage in the biliary tract and most commonly associated with accidental or iatrogenic trauma, is a rare complication of RFA. Here we report a case of hemocholecyst associated with hemobilia after RFA for hepatocellular carcinoma that was successfully managed by laparoscopic cholecystectomy.