Hemobilia and pancreatitis after liver transplant biopsy

Abstract

A 51-year-old male presented after liver transplant biopsy with severe abdominal pain. This occurred 2 years after a combined liver-kidney transplant for end-stage liver disease from alcoholic cirrhosis and end-stage renal disease from chronic glomerulonephritis. His posttransplantation course was unremarkable. His other medical history included hypertension. His was not on any anticoagulation medication, and his maintenance immunosuppression included tacrolimus and mycophenolate mofetil. His liver and kidney function prior to biopsy was normal (Table 1). At our institution, patients routinely undergo surveillance liver biopsy on a yearly basis, and this was the only indication for biopsy. ALT, alanine aminotransferase; AST, aspartate aminotransferase; CT, computed tomography; HCT, hematocrit; HGB, hemoglobin; MRCP, magnetic resonance cholangiopancreatography; N/A, not applicable. The biopsy was performed in the right lobe by interventional radiology under ultrasonographic guidance with an 18-gauge BioPrince biopsy gun. A Doppler ultrasound prior to biopsy was unremarkable. One hour after the biopsy, the patient developed severe abdominal pain. A noncontrast computed tomography (CT) scan of the abdomen looking for subcapsular hematoma revealed an intraluminal density in the second and third portions of the duodenum. Immediately after the CT scan, the patient passed a large bloody stool. Upon further review of the CT scan, the intraluminal densities in the duodenum were thought to be blood clots. The patient remained hemodynamically stable. His repeat laboratory values are listed in Table 1. His hemoglobin had dropped from 17.4 to 15.6 g/L, his total bilirubin had increased to 5.2 mg/dL, and his lipase was 1800 IU/L. At that time, he was made nil per os and was treated with intravenous hydration and antibiotics. Magnetic resonance cholangiopancreatography (MRCP) was then obtained (Fig. 1). The MRCP demonstrated significant hemobilia, including obstructing blood clots within the common bile duct that were likely also occluding the pancreatic duct. The patient responded well to conservative therapy. The day after admission, he passed a nonbloody stool, and his abdominal pain improved. His laboratory values all showed significant improvement (Table 1). A repeat MRCP demonstrated resolution of the hemobilia. His diet was reinstituted, and he was discharged 2 days after admission. Series of coronal images (a,b,c) from a magnetic resonance cholangiopancreaticogram. An irregular filling defect, consistent with hemobilia (blood clot a,b,c), is present in the lower third of the common bile duct, with a clot possibly obstructing the pancreatic duct (b). Hemobilia is a rare complication of liver biopsy and can lead to pancreatitis. In this case, the bleeding was transient, and conservative management was successful. However, had the hemobilia continued, the patient may have needed a hepatic angiogram with embolization. Also, if the common bile duct and/or pancreatic duct had remained obstructed from the blood clots, a therapeutic endoscopic retrograde cholangiopancreaticogram may have been necessary for clot extraction.