Tears of blood: an unusual case of haemolacria due to conjunctival vascular malformation successfully managed by embolisation.

A boy in his mid-teens presented with progressively increasing bleeding from the right eye and nostril intermittently over a period of 6 weeks. A complete ophthalmic examination revealed nothing significant. His otorhinological examination and haematological investigations were within normal limits. The patient came a month later with frank bleeding from the right eye. Ophthalmic examination revealed hyperaemia and maceration of the right lower palpebral conjunctiva. A histopathological examination of conjunctival scrapings from the site showed abnormal dilated blood vessels suggestive of a vascular malformation. Digital subtraction angiography confirmed the presence of a conjunctival micro arteriovenous malformation supplied by the external carotid and ophthalmic artery branches. He underwent successful transarterial Onyx embolisation resulting in complete resolution of the haemolacria.

Successful Endovascular Management of Pseudoaneurysm following Transarterial Chemoembolization: A Case Report.

Background and Objectives: Transarterial chemoembolization (TACE) is a widely accepted treatment for hepatocellular carcinoma (HCC). Regarding TACE, arterial injuries, such as hepatic artery spasm or dissection, can also occur, although pseudoaneurysms are rare. We report a case of pseudoaneurysm following TACE. Materials and Methods: A 78-year-old man had been undergoing TACE for HCC in segment 8 of the liver for the past 5 years, with the most recent TACE procedure performed approximately 1 month prior. He presented to the emergency department with melena that persisted for 5 days. Computed tomography revealed a pseudoaneurysm in the S8 hepatic artery with hemobilia. Results: the pseudoaneurysm was successfully treated by N-Butyl-cyanoacrylate glue embolization. Conclusions: In patients that have undergone TACE presenting with melena and hemobilia identified on CT, consideration of hepatic artery pseudoaneurysm is crucial. Such cases can be safely and effectively treated with endovascular managements.

A rare incidence of a hepatic artery pseudoaneurysm following plastic biliary stent insertion.

Hepatic artery pseudoaneurysms have been reported to occur in approximately 1% of cases after metal stenting for malignant biliary obstruction. In contrast, only a few cases have been reported as complications after plastic stenting for benign biliary disease. We report a 61-year-old man with cholangitis who presented with a rare complication of hemobilia after implantation of 7 Fr double pigtail plastic biliary stents. No bleeding was observed approximately one month after biliary stent tube removal. Contrast-enhanced CT scan revealed a circularly enhanced lesion (5 mm in diameter) in the arterial phase at the tip of the previously inserted plastic bile duct stent. Color Doppler ultrasonography enhanced the lesion and detected arterial blood flow inside. He was diagnosed with a hepatic artery pseudoaneurysm. However, he had no risk factors such as prolonged catheterization, severe cholangitis, liver abscess, or long-term steroid use. Superselective transarterial embolization using two metal microcoils was successfully completed without damage to the surrounding liver parenchyma. If hemobilia is suspected after insertion of a plastic bile duct stent, immediate monitoring using contrast-enhanced computed tomography or Doppler ultrasonography is recommended.

Multidisciplinary management of high-grade pediatric liver injuries.

OBJECTIVE: To present our experience of multidisciplinary management of high-grade pediatric liver injuries. INTRODUCTION: Pediatric high-grade liver injuries pose significant challenge to management due to associated morbidity and mortality. Emergency surgical intervention to control hemorrhage and biliary leak in these patients is usually suboptimal. Conservative management in selected high-grade liver injuries is now becoming standard of care. Management of hemobilia due to pseudoaneurysm formation and traumatic bile leaks requires multidisciplinary management. METHODS: A retrospective review was undertaken for patients presenting with blunt liver injuries at two tertiary care centers in Karachi, Pakistan, from March 2021 to December 2022. Twenty-eight patients were identified, and four patients fulfilled the criteria for grade 4 and above blunt liver injury during this period. RESULTS: One case with grade 4 liver injury developed hemobilia on 7th day of injury. He required two settings of angioembolization but had recurrent leak from pseudoaneurysm. He ultimately needed right hepatic artery ligation. Second patient presented with massive biliary peritonitis 2 days following injury. He was managed initially with tube laparostomy followed by ERCP and stent placement. The third patient developed large hemoperitoneum managed conservatively. One case with grade 5 injury expired during emergency surgery. CONCLUSION: Conservative management of advanced liver injuries can result in significant morbidity and mortality due to high risk of complications. Trauma surgeons need to have multidisciplinary team for management of these patients to gain optimal outcome.

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.

Pseudoaneurisma no traumático de la arteria cística como causa de hemobilia / Non traumatic pseudoaneurysm of the cystic artery as a cause of haemobilia

No disponible

Hemobilia como complicación inusual de la biopsia hepática, hallazgos en resonancia magnética / Hemobilia as unusual complication of liver biopsy, magnetic resonance findings

No disponible

Percutaneous Metallic Stent Placement for Palliative Management of Malignant Biliary Hilar Obstruction

OBJECTIVE: To investigate the outcomes of percutaneous metallic stent placements in patients with malignant biliary hilar obstruction (MBHO). MATERIALS AND METHODS: From January 2007 to December 2014, 415 patients (mean age, 65 years; 261 men [62.8%]) with MBHO were retrospectively studied. All the patients underwent unilateral or bilateral stenting in a T, Y, or crisscross configuration utilizing covered or uncovered stents. The clinical outcomes evaluated were technical and clinical success, complications, overall survival rates, and stent occlusion-free survival. RESULTS: A total of 784 stents were successfully placed in 415 patients. Fifty-five patients had complications. These complications included hemobilia (n = 19), cholangitis (n = 13), cholecystitis (n = 11), bilomas (n = 10), peritonitis (n = 1), and hepatic vein-biliary fistula (n = 1). Clinical success was achieved in 370 patients (89.1%). Ninety-seven patients were lost to follow-up. Stent dysfunction due to tumor ingrowth (n = 107), sludge incrustation (n = 44), and other causes (n = 3) occurred in 154 of 318 patients. The median overall survival and the stent occlusion-free survival were 212 days (95% confidence interval [CI], 186−237 days) and 141 days (95% CI, 126−156 days), respectively. The stent type and its configuration did not affect technical success, complications, successful internal drainage, overall survival, or stent occlusion-free survival. CONCLUSION: Percutaneous stent placement may be safe and effective for internal drainage in patients with MBHO. Furthermore, stent type and configuration may not significantly affect clinical outcomes.

A Ruptured Cystic Artery Pseudoaneurysm with Concurrent Cholecystoduodenal Fistula: A Case Report and Literature Review

Pseudoaneurysms of the cystic artery and cholecystoduodenal fistula formation are rare complications of cholecystitis and either may result from an inflammatory process in the abdomen. A 68-year-old man admitted with acute cholecystitis subsequently developed massive upper gastrointestinal (GI) bleeding. Abdominal computed tomography showed acute calculous cholecystitis and hemobilia secondary to bleeding from the cystic artery. Angiography suggested a ruptured pseudoaneurysm of the cystic artery. Upper GI endoscopy showed a deep active ulcer with an opening that was suspected to be that of a fistula at the duodenal bulb. The patient was managed successfully with multimodality treatment that included embolization followed by elective laparoscopic cholecystectomy. Presently, there is no clear consensus regarding the clinical management of this disease. We have been able to confirm various clinical features, diagnoses, and treatments of this disease through a literature review. A multidisciplinary approach through interagency/interdepartmental collaboration is necessary for better management of this disease.

Double-Stent System with Long Duodenal Extension for Palliative Treatment of Malignant Extrahepatic Biliary Obstructions: A Prospective Study

OBJECTIVE: To investigate the technical safety and clinical efficacy of a double-stent system with long duodenal extension in patients with malignant extrahepatic biliary obstruction. MATERIALS AND METHODS: This prospective study enrolled 48 consecutive patients (31 men, 17 women; mean age, 61 years; age range, 31–77 years) with malignant extrahepatic biliary obstructions from May 2013 to December 2015. All patients were treated with a double-stent system with long duodenal covered extension (16 cm or 21 cm). RESULTS: The stents were successfully placed in all 48 patients. There were five (10.4%) procedure-related complications. Minor complications were self-limiting hemobilia (n = 2). Major complications included acute pancreatitis (n = 1) and acute cholecystitis (n = 2). Successful internal drainage was achieved in 42 (87.5%) patients. Median patient survival and stent patency times were 92 days (95% confidence interval [CI], 61–123 days) and 83 days (95% CI, 46–120 days), respectively. Ten (23.8%) of the 42 patients presented with stent occlusion due to food impaction with biliary sludge, and required repeat intervention. Stent occlusion was more frequent in metastatic gastric cancer patients with pervious gastrectomy, but did not reach statistical significance (p = 0.069). CONCLUSION: Percutaneous placement of a double-stent system with long duodenal extension is feasible and safe. However, this stent system does not completely prevent stent occlusion caused by food reflux.

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.

Hemobilia por pseudoaneurisma de la arteria cística en ecografía / Hemobilia due to a cystic artery pseudoaneurysm on ultrasound

No disponible

Pancreatitis aguda por hemobilia secundaria a pseudoaneurisma de la arteria cística / Hemobilia related to cystic artery pseudoaneurysm as a cause of acute pancreatitis

No disponible

Hemobilia por neoplasia papilar intracolecística / Hemobilia due to intracholecystic papillary neoplasm

Exponemos el caso de un paciente de 39 años que presentó un episodio de hemorragia digestiva alta secundario a hemobilia. Mediante las pruebas de imagen realizadas se objetivó ocupación de la vesícula biliar por tejido sólido, que tras colecistectomía se diagnosticó de neoplasia papilar intracolecística. Se trata una entidad recientemente establecida y se considera un subtipo de la neoplasia papilar intraductal de la vía biliar. La presentación en forma de hemobilia apenas ha sido descrita en la literatura (AU)

No disponible

An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications

Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%–45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques—such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy—combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.

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.

Post-Endoscopic Sphincterotomy Bleeding: Strategic Approach with Multiple Endoscopic Arms / 대한췌담도학회지

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential method for diagnosis and treatment of various pancreatobiliary diseases and endoscopic sphincterotomy (EST) is the gateway to complete ERCP. Although techniques and instruments for EST have improved, bleeding is still the most common complication. Treatment of immediate post-EST bleeding is important because blood can interfere with subsequent procedures. Additionally, endoscopists should be cautious about delayed bleeding may cause hemobilia, cholangitis, and hemodynamic shock. Most cases of post-EST bleedings will stop spontaneously, however, endoscopic management is necessary in case of clinically significant and persistent bleeding. Various endoscopic methods including epinephrine or fibrin glue injection, electrocoagulation, hemoclipping and band ligation et al can be used through a sideviewing or forward-viewing endoscope similar to those used in hemostasis of peptic ulcer bleeding. Endoscopists who perform ERCP should use various methods of endoscopic hemostasis strategically.