Hemobilia.

Abstract

Hemobilia, which may be defined as hemorrhage into the biliary tract (14), is an uncommon cause of gastrointestinal blood loss. Numerous reports have described the chronic loss of blood that occurs with neoplasms of the ampulla of Vater, biliary stones, and other lesions of the biliary tract, but massive hemobilia, with severe acute gastrointestinal hemorrhage as the presenting symptom, is rare. Several articles have been published on the various causes for massive biliary hemorrhage, chiefly in surgical journals; no discussion of this problem has appeared in the radiological literature. Since most patients with severe gastrointestinal hemorrhage are examined in the department of radiology by means of various contrast studies, it is felt that an awareness of this unusual source of bleeding should be of interest and value. This report will review the various causes of massive hemobilia and discuss in more detail traumatic hemobilia as illustrated by a case. Review of the Literature The most common causes for massive hemobilia are aneurysm of the hepatic artery and liver trauma. To date there have been reported approximately 50 cases of aneurysm and 20 of trauma associated with severe gastrointestinal hemorrhage. Sixty per cent of aneurysms of the hepatic artery have been thought to be secondary to infection; arteriosclerosis and trauma are less common causes. The preoperative diagnosis of the aneurysm is usually impossible. Grant et al. (4), in their study of hepatic artery aneurysms, found pain, often mimicking biliary colic, in 80 per cent, hemobilia in 63 per cent, and jaundice in 55 per cent. Other nonspecific symptoms, including indigestion and flatulence, also occur. In a rare case, the liver may be enlarged, with a pulsating tumor, a palpable thrill, and a systolic bruit. These last signs, which should suggest the diagnosis, are most uncommon. If the aneurysm lies extrahepatically, the diagnosis is obvious at surgery. With an intrahepatic aneurysm, however, the necessity of an operative arteriogram arises. The gastrointestinal hemorrhage in these cases is due to erosion of the aneurysm into either the biliary tract or both the biliary and the gastrointestinal tract. Mackay and Page (9) have discussed the treatment of this condition thoroughly. Causes of massive hemobilia other than aneurysm or trauma are rare. Fisher and Creed (3) described a primary hepatoma which led to severe gastrointestinal bleeding and to biliary obstruction by an intrabiliary blood clot. Similarly, gallbladdertumors (5) and bile duct adenoma (19) have been reported as causes of massive gastrointestinal hemorrhage. At least 3 cases have been secondary to the placing of a T-tube in the common bile duct (10, 13). In the case reported by Manfredi (10) a Ttube introduced into the common duct following a cholecystectomy led to erosion into the hepatic artery and exsanguination.