Acute Pancreatitis Caused by Hemobilia From a Hepatic Artery Pseudoaneurysm

Abstract

Introduction: Hemobilia, defined as hemorrhage into the biliary tract, is caused by a pathological communication between hepatic vessels and bile ducts. The most common etiology of hemobilia is trauma, followed by gallstones, inflammatory diseases, vascular lesions, and neoplasms. Hemobilia classically presents as a clinical triad of biliary colic, jaundice, and upper gastrointestinal tract bleed, though the typical symptoms are only found in about 40% of cases. Acute pancreatitis is an unusual presentation of hemobilia. The proposed mechanism is that blood in the biliary system causes obstruction of the pancreatic and common bile duct, leading to pancreatitis and obstructive jaundice. We report a case of hemobilia-induced pancreatitis secondary to a hepatic artery pseudoaneurysm. Case Report: A 36-year-old female with a history of methamphetamine use presented with 1 day of epigastric abdominal pain with nausea and nonbloody, nonbilious emesis. There was no history of trauma or recent procedures. On physical exam, the patient had tenderness to palpation in the epigastric region without peritoneal signs. Exam was notable for mild scleral icterus. She had no stigmata of chronic liver disease or organomegaly. Labs revealed a leukocyte count of 8900/mm3, aspartate aminotransferase 188 U/L, alanine aminotransferase 143 U/L, total bilirubin 2.4 mg/dL, which increased to 7.2 mg/dL the following day, alkaline phosphatase 183 U/L, and lipase 2583 U/L. Abdominal ultrasound showed 2 stones within the gallbladder lumen and normal-sized bile duct. The patient was admitted for management of acute pancreatitis. EUS and ERCP were performed with visualization of large blood clots occluding the ampulla. Biliary sphincterotomy led to removal of large blood clots; no stones were retrieved from the bile duct. The source of bleeding was not identified. Post-procedure, the patient clinically improved with resolution of abdominal pain and normalization of lipase and total bilirubin. Hepatic angiography revealed a right hepatic artery superior branch pseudoaneurysm that was thought to be the cause of hemobilia. Coil embolization was performed, which resulted in successful hemostasis. Discussion: We describe a case of hemobilia from a bleeding hepatic artery pseudoaneurysm with an atypical presentation of acute pancreatitis. The most common cause of hemobilia is trauma, with an increasing incidence of iatrogenic trauma. However, we should maintain a high index of suspicion for hemobilia caused by other etiologies as seen in this case.