Hemobilia after Laparoscopic Cholecystectomy

Abstract

Hemobilia is a rare complication of laparoscopic cholecystectomy. We present a case of hemobilia seven days after laparoscopic cholecystectomy. Clinical presentation, radiologic findings, outcome, and management are discussed. A review of the literature is also performed. Case Report: A 50 y.o. female underwent an uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis. One week after surgery, she was admitted to the hospital with a three-day history of RUQ pain, nausea, vomiting, and abnormal liver function tests (bilirubin – 2.1 mg/dl, alkaline phosphatase – 138 IU/L, AST – 645 IU/L, and ALT – 273 IU/L). HIDA scan was normal, and CT scan described a possible hematoma in the gallbladder fossa. Three days after admission, the bilirubin increased to 4.9 mg/dl and the hematocrit decreased from 42% to 34.8%. The patient underwent an ERCP which showed active bleeding from the major ampulla. A cholangiogram demonstrated multiple filling defects in the common bile duct and common hepatic duct with no ductal dilatation. Sphincterotomy was performed and a balloon was dragged through the common bile duct. A few blood clots were obtained. An arteriogram was done which showed a thrombus at the base of the right hepatic artery with possible dissection. There was no pseudoaneurysm. No active bleeding was found nor was embolization done. The patient remained clinically stable with eventual normalization of liver function tests. Discussion: Hemobilia is a rare complication which is mostly caused by either blunt or penetrating trauma (up to 48% of cases). It is also described in cases of infection, gallstones, tumor, pancreatitis, and aneurysms. Only a few cases have been reported as a complication from laparoscopic cholecystectomy. Imaging studies that may help in the diagnosis are CT scan, RUQ ultrasound, and HIDA scan. ERCP confirms the diagnosis, after which an arteriogram should be done as it is the most accurate test to locate the lesion; it can also be therapeutic with embolization of the bleeding vessel. The patient presented in this case remained clinically stable without further surgical or medical intervention. Hemobilia should be considered in a patient presenting with abdominal pain and abnormal liver function tests after laparoscopic cholecystectomy.