Hemobilia, Cholangitis, Pancreatitis, and Cholecystitis after CT-Guided Percutaneous Liver Biopsy

Abstract

Purpose: Hemobilia presents as a classic triad of gastrointestinal bleeding, right upper quadrant pain and jaundice. Incidence of hemobilia is 0.06–1% with percutaneous liver biopsy. Presented is a rare case of a hepatic biopsy-related triple complication including cholangitis, pancreatitis and cholecystitis from hemobilia. Methods: A 48-year-old man with a history of chronic hepatitis C and alcohol abuse presented with epigastric abdominal pain, nausea and low grade fevers 7 days after a CT-guided liver biopsy. On presentation he was icteric. His abdomen was slightly distended with mild generalized tenderness worse in RUQ. His laboratory evaluation revealed a WBC of 9000/mm3, Hgb/Hct of 17.1 gm/dL and 49. Platelets were 169,000. Serum AST was 372 U/L, ALT 235 U/L, AP 198 U/L and T Billi (TB) 5.68 mg/dL (DB 4.85). Amylase and lipase were 189 U/L and 339 U/L respectively. An abdominal US showed normal common bile duct (CBD) with gallbladder (GB) sludge. CT scan of the abdomen revealed hyperdense material filling the GB. He was treated with IV fluids and antibiotics. On ERCP, blood was seen emanating from the ampulla. Multiple blood clots (CBD filling defects) were balloon extracted. A nasobiliary (NB) tube was left in CBD. On angiography no active bleeding was visualized. Results: The patient pulled out the NB tube and left against medical advice only to return the day after with worsening abdominal pain, fevers and rising LFTs. An abdominal US revealed a thickened GB wall. Repeat ERCP revealed no filling of the GB. Another NB tube was placed in the CBD. A hepatobiliary scan showed no filling of the GB or the CBD suggesting an obstruction. NB tube cholangiogram revealed no CBD filling defects. A repeat hepatobiliary scan showed resolution of CBD obstruction but no GB filling. During surgery the GB had a dusky, thickened (0.8 cm) wall and contained 5 ml of clotted blood. He made an uneventful recovery post-surgery and was discharged. Conclusions: Hemobilia may occur immediately following liver biopsy or may be delayed by weeks. It results from needle tract connection of the hepatic artery, portal vein or both to the biliary tree. If suspected, early ERCP is advisable which can be therapeutic. Hepatic artery embolization or surgery maybe needed. Complications including cholecystitis, cholangitis and pancreatitis should be differentiated from primary pancreatitis, hemorrhagic cholecystitis and cholangitis causing hemobilia.