Haemobilia is a medical condition of bleeding into the biliary tree. Haemobilia occurs when there is a fistula between a vessel of the splanchnic circulation and the intrahepatic or extrahepatic biliary system. It can present as acute upper gastrointestinal (UGI) bleeding. It should be considered in upper abdominal pain presenting with UGI bleeding especially when there is a history of liver injury or instrumentation. First recorded in 1654 by Francis Glisson, a Cambridge professor.

Presentation

Quincke's triad of upper abdominal pain, upper gastrointestinal haemorrhage and

jaundice Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and sclera due to high bilirubin levels. Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme meta ...

is classical but only present in 22% cases. It can be immediately life-threatening in major bleeding. However, in minor haemobilia, patient is haemodynamically stable despite significant blood loss being apparent.

Causes

The causes of haemobilia include trauma (which can be accidental or iatrogenic due to procedures such as

cholecystectomy Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the eighth most common operating room procedure performed i ...

), instrumentation (especially after

ERCP Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is primarily performed by highly skille ...

), gallstone, inflammatory conditions ranging from

ascariasis Ascariasis is a disease caused by the parasitic roundworm ''Ascaris lumbricoides''. Infections have no symptoms in more than 85% of cases, especially if the number of worms is small. Symptoms increase with the number of worms present and may in ...

to PAN, vascular malformation, tumors,

coagulopathy Coagulopathy (also called a bleeding disorder) is a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding (bleeding diathesis), which may occur spo ...

, and liver biopsy.

Diagnosis

Combination of EGD,

CT scan A computed tomography scan (CT scan; formerly called computed axial tomography scan or CAT scan) is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers ...

and angiography depending on clinical situation, bearing in mind that haemobilia may present many days after injury. Cholangiography is performed if there is a percutaneous access or if

is undertaken.

Management

Most bleeding from instrumentation are minor and would settle spontaneously. When indicated, management is directed towards stopping bleeding and relieving obstruction if present, which is achieved either by

surgical ligation In surgery or medical procedure, a ligature consists of a piece of thread ( suture) tied around an anatomical structure, usually a blood vessel or another hollow structure (e.g. urethra) to shut it off. History The principle of ligation is attr ...

of hepatic artery or by

endovascular Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as Fluoroscopy, x-ray fluoroscopy, CT scan, computed tomography, magnetic resonance imaging, or ultraso ...

embolisation. Endovascular trans-arterial embolisation (TAE) is preferred initially because of high success rate and less complication. TAE involves the selective catheterization of a hepatic artery followed by embolic occlusion. Surgery is indicated when TAE has failed or sepsis present in biliary tree or drainage has failed.

References

External links

CT of the abdomen with hemobilia
{{Bleeding and clotting disorders Gastroenterology Bleeding Hepatology