1392 Transjugular Liver Biopsy Causing Hemobilia and the Rarely Reported Hemocholecystitis

Abstract

INTRODUCTION: Transjugular liver biopsy is a safe and effective tool in liver disease patients in whom percutaneous liver biopsy is contraindicated. Serious complications from transjugular liver biopsy are uncommon. Liver biopsy related hemobilia occurs in less than 1% of cases and hemobilia related hemocholecystitis is very rare. CASE DESCRIPTION/METHODS: A 56-year old Asian male with ESRD presented with abdominal pain and melena. 3 days prior to presentation he had undergone a transjugular liver biopsy for evaluation of abnormal LFTs and cirrhotic appearing liver on imaging. Vital signs were normal. Exam was significant for epigastric tenderness. Labs with Hb 10.4 gm/dL, Bili 1.1 mg/dL, ALP 307 U/L, AST 131 U/L, ALT 64 U/L, INR 1, and lipase 5069 U/L. CT abdomen showed a distended gallbladder with ovoid debris within (Figure 1). EGD was with no obvious luminal blood. MRCP showed distended gallbladder with a large sludge ball within, normal CBD, and mild pancreatic head edema. Tagged RBC scan was negative. With continued worsening of LFTs and ongoing gradual decline in Hb, patient was suspected to have intermittent hemobilia and biliary obstruction. ERCP showed bulging major papilla with a trace of blood at the orifice. Cholangiogram showed no obvious filling defects in the bile duct. Gallbladder was un-opacified denoting cystic duct obstruction (Figure 2). Biliary sphincterotomy was performed and balloon sweep of the biliary tree was unremarkable except for some minimal sludge. A plastic stent was placed in the CBD. Patient continued to have worsening right upper quadrant abdominal pain with clinical suspicion for acute cholecystitis. Patient underwent laparoscopic cholecystectomy revealing an edematous and severely inflamed gallbladder. Gallbladder lumen contained bloody bile and blood clots. Microscopic examination of gallbladder revealed extensive wall necrosis and acute inflammation (Figure 3). Patient had an uneventful post-operative course. DISCUSSION: Hemobilia after liver biopsy is rare and occurs in less than 1% cases. Acute cholecystitis from hemobilia (hemocholecystitis) is extremely rare and is due to thrombus obstructing the cystic duct. Diagnosing hemocholecystitis is challenging and clinicians need a high index of suspicion in making this diagnosis and thus prevent delay of much needed definitive treatment. Ultrasound and HIDA scan can be useful in making diagnosis. Risk of gallbladder perforation in these cases is 2-15% from gangrenous cholecystitis. Treatment of hemocholecystitis is early cholecystectomy.