Fatal bilhemia

Abstract

If trauma to the liver results in a passage (fistula) between the biliary tract and blood vessels, there will be either a flow of blood into the bile ducts (hemobilia) or of bile into the bloodstream (bilhemia). 1 Sandblom P. Hemorrhage into the biliary tract following trauma “traumatic hemobilia.”. Surgery. 1948; 24: 571 PubMed Google Scholar , 2 Sandblom P. Haemobilia. in: 2nd ed. Surgery of the liver and biliary tract. : Churchill Livingston, Edinburgh1994: 1273 Google Scholar , 3 Clemens M Wittrin G Bilhämie und hämobilie nach Reitunfall. : Tagung Nordwest-deutscher Chirurgen, Hamburg1975 Google Scholar The direction of the flow depends on the pressure gradient between the 2 systems. 2 Sandblom P. Haemobilia. in: 2nd ed. Surgery of the liver and biliary tract. : Churchill Livingston, Edinburgh1994: 1273 Google Scholar Because blood pressure generally exceeds pressure in the bile ducts, hemobilia is, by far, the more common problem. Flow in the opposite direction, bilhemia, occurs in the rare patients in whom the normal pressure gradient is inverted, directing bile into the hepatic veins or the portal vein. 3 Clemens M Wittrin G Bilhämie und hämobilie nach Reitunfall. : Tagung Nordwest-deutscher Chirurgen, Hamburg1975 Google Scholar , 4 Lagagne PM Lacaine F Bonnel D Ligory CL Huguier M. Bilioportal fistula as a complication of choledochoduodenostomy. Surgery. 1988; 103: 125 PubMed Google Scholar This inversion of the usual pressure gradient (blood pressure greater than biliary pressure) may be caused by obstruction of bile flow. In a large series of patients with obstructive jaundice, the pressure in the bile ducts was invariably greater than in the hepatic vein. 5 Wiechel Kl. Percutaneous transhepatic cholangiography: technique and complication, with studies of the hepatic venous and biliary duct pressures, the chemical changes in blood and bile and clinical research in a series of jaundiced patients. Acta Chir Scand. 1964; 99: 330 Google Scholar On occasion, this pressure may also exceed the normal portal pressure. Low venous pressure may promote bilhemia. In 5 instances, gallstones have eroded into the portal vein. 2 Sandblom P. Haemobilia. in: 2nd ed. Surgery of the liver and biliary tract. : Churchill Livingston, Edinburgh1994: 1273 Google Scholar The first report was in 1559, and thus preceded the first description of hemobilia by a century; at the necropsy of Ignatius Loyola, 3 stones were found in the portal vein.