Acute Upper Gastrointestinal Bleeding: Think Outside the Ampulla

Abstract

Bleeding from the hepatobiliary tract (hemobilia), is a rare cause of an acute upper GI bleed. It should be considered in any patient with a recent history of hepatic parenchymal or biliary intervention, angioembolization, blunt abdominal trauma or hepatic malignancy. We describe a case of hemobilia due to hepatocellular carcinoma (HCC) invading the gallbladder wall.Figure. 3: 1 cm oval-shaped, arterial-phase enhancing lesion in the lateral aspect of the right hepatic lobe (arrow) suspicious for residual HCC within close proximity to the gallbladder.Figure: EGD demonstrating blood oozing within the 2nd portion on the duodenum (A) and oozing from the Ampulla of Vater (B).A 52 year-old female with PMHx of Laennec's cirrhosis complicated by HCC status post transarterial chemoembolization (TACE) presented with black tarry stools, dizziness and abdominal pain. Physical exam was significant for right upper quadrant tenderness to palpation and melanotic stools. Labs were consistent with severe anemia, thrombocytopenia and liver profile derangement. An MRI performed the month prior to admission, demonstrated a 3.1 cm oval-shaped, arterial-phase enhancing lesion in the lateral aspect of the right hepatic lobe, suspicious for residual HCC (fig. A). She was aggressively transfused multiple blood products and placed on a proton pump inhibitor and octreotide drip. An emergent EGD was performed which identified blood oozing from the Ampulla of Vader; consistent with a diagnosis of hemobilia (fig. B). A CTA was negative for active extravasation. The presumed etiology was invasion of the residual HCC into the gallbladder wall given the close proximity identified on MRI. Given her history of TACE and severe liver dysfunction, she was not a candidate for embolization and she was medically managed. First recorded in 1654 by Francis Glisson, hemobilia is an exceedingly rare condition with an unknown exact incidence. Traumatic etiology accounts for 40 - 80 percent of all cases. In patients with HCC, invasion into the blood vessels (most commonly portal vein) is a frequent feature, however gallbladder and ductal invasion is widely unrecognized. One study involving 24 patients with HCC was performed to describe the features of intra-bile duct invasion. 21% developed hemobilia; one patient subsequently died from hemorrhagic shock. Approximately one-third of all patients will present with Quincke's triad: acute upper GI bleed (100%), biliary colic (70%) and jaundice (60%). Diagnosis is by visualizing blood from the Ampulla of Vader via EGD or ERCP. The best diagnostic and therapeutic intervention is angiography with embolization (success rate > 95%). Despite aggressive intervention, severe hemobilia has been shown to have a mortality as high as 25%.