A Mysterious Cause of Upper Gastrointestinal Bleeding Presenting Surreptitiously

Abstract

Purpose: Hemobilia, or hemorrhage into the biliary tract, is a rare cause of upper gastrointestinal bleeding (1%), but the frequency is increasing due to application of hepatobiliary diagnostic modalities such as endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreaticography (ERCP). More than 50% of cases of hemobilia are related to iatrogenic trauma from invasive hepatobiliary procedures, most commonly, a liver biopsy. The most classic presentation of hemobilia is the triad of right upper quadrant (biliary) pain, obstructive jaundice with biliary duct dilation on ultrasound, and melena. We encountered a rare case of hemobilia that occurred in the absence of iatrogenic trauma, medical history of hepatobiliary disease, biliary ductal dilation, or the classic triad of signs and symptoms described above. Results: Case: A 91-year-old African American female with an unremarkable past medical history presented with mild epigastric pain and melena that had been occurring for a week. Laboratory data revealed a hematocrit of 30 and an alkaline phosphatase of 664 (International Units per Liter) without evidence of hyperbilirubinemia. Abdominal ultrasound studies were remarkable for multiple hepatic cysts without evidence of biliary ductal dilation. Esophagogastroduodenoscopy revealed multiple blood clots at the Ampulla of Vater. ERCP findings were noteworthy for multiple filling defects in the common hepatic duct and common bile duct, which turned out to be blood clots. All the blood clots were removed from the common bile duct during ERCP and the patency of the bile duct was established. ERCP was able to show that a hepatic cyst hemorrhage was communicating with the common hepatic duct. The presumptive cause of upper gastrointestinal (GI) bleeding in this case was a hepatic cyst hemorrhage, which is a rare cause of hemobilia. Conclusion: Hemobilia is a rare cause of upper GI bleeding that should be considered in patients with melena, right upper abdominal pain, and cholestasis. This case illustrates the development of hemobilia in the absence of biliary duct dilation, iatrogenic trauma, and significant hepatobiliary disorders.Table: Causes of hemobilia