A Rare Cause of Obstructive Jaundice: A Case Report

Abstract

An 81-year-old man with myelodysplastic syndrome and transfusion-dependent anemia was admitted to the hospital for evaluation of jaundice and dark urine of 1-day duration. He denied abdominal pain, nausea, vomiting, melena, rectal bleeding or pale stool. There was no prior history of biliary interventions or trauma. Vitals were within normal limits and he was afebrile. Physical examination was significant for icterus. Laboratory values were- Hb - 5.1 from 8.1 gm/dL 1 week ago, Platelet count -34 K/ul, alanine aminotransferase- 430 IU/L, aspartate aminotransferase- 212 IU/L, alkaline phosphatase-288 IU/L, gamma glutamyl transferase- 918 IU/L, total bilirubin-6.4 mg/dL, direct bilirubin-5.01 mg/dL and INR-1.2. CT abdomen and pelvis revealed intrahepatic biliary dilatation and common bile duct dilatation of 1.1 cm. An endoscopic retrograde cholangiopancreatography [ERCP] was performed and cholangiogram showed multiple elongated deformed filling defects in the main bile duct [figure-1]. Biliary sphincterotomy and balloon sweep was performed that removed numerous large old blood clots from the CBD [figure-2]. Bile duct was adequately irrigated with sterile water and all remaining clots were cleared. Occlusion cholangiogram showed no more filling defects [figure-3]. There were no stones seen or extracted during the entire procedure. Patient required 2 units of blood and 2 units of platelets transfusion prior to the procedure and no post-procedural bleeding was observed. Bilirubin and liver enzymes trended down and hemoglobin remained stable. Patient was discharged home after clinical recovery. Discussion Iatrogenic or accidental trauma from hepatobiliary procedures is the most common etiology for haemobilia. It can also occur as part of certain disorders such as cholangitis, hepatobiliary cyst/cancers, choledocholithiasis and vascular abnormalities in the liver. However, spontaneous haemobilia is rarely reported in literature. Triad of upper abdominal pain, gastrointestinal bleeding, and jaundice are the common clinical presentations. This case is unique in that our patient had obstructive jaundice in the absence of other clinical symptoms such as abdominal pain, hematemesis or melena. Management of haemobilia is aimed at control of bleeding and relieving biliary obstruction. ERCP is helpful in diagnosing the cause of haemobilia and relieving biliary obstruction but trans arterial embolization is the gold standard in management of haemobilia.1244_A.tif Figure 1: Cholangiogram with multiple filling defects1244_B.tif Figure 2: Old blood clots at ampulla1244_C.tif Figure 3: Occlusion cholangiogram after biliary irrigation