Quinckeʼs Triad: A Rare Complication of a Common Outpatient Procedure

Abstract

Purpose: We describe the case of a 64 year old male who presented to our hospital with RUQ pain five days after ultrasound-guided liver biopsy at an outside hospital. The pain was intermittent, sharp and worsened by deep breathing and movement. It was associated with black stool, pruritus and dark urine. He was found to have icteric sclera and mild pallor. His abdomen was soft, non-distended and mildly tender in the RUQ. Rectal exam was positive for melenic stool. Lab results revealed an elevated total bilirubin of 8 mg/dl along with elevated amylase and lipase of 4022 and 3957 U/L respectively. AST, ALT and ALP were elevated at 264, 118 and 269 U/L respectively. Hemoglobin was marginally decreased at 10.4 g/dL. Stool was heme positive and urine positive for urobilinogen and bilirubin. Abdominal ultrasound showed echogenic matter in the gallbladder suspicious for blood. On upper endoscopy blood was seen in the second part of the duodenum with a clot adherent to the ampulla of Vater. Upon irrigation, the clot was removed and there was active bleeding from the common bile duct. Hepatic angiography was done however the culprit vessel could not be found despite two separate attempts by two separate interventional radiologists. After staying ten days and receiving fourteen units of blood, the hemobilia resolved spontaneously and the patient was discharged. DISCUSSION: Hemobilia was first published by Francis Glisson in 1654. Its incidence after liver biopsy has been reported as less than one in a thousand. The first case of hemobilia following liver biopsy was reported in 1967. It is usually due to bleeding from an intrahepatic branch of the hepatic artery into a biliary duct. The time between liver biopsy and onset of hemobilia averages about five days. In 1870, Heinrich Quincke described the triad of jaundice, biliary colic and gastrointestinal bleeding in a patient with a ruptured hepatic artery aneurysm who developed hemobilia. This triad only presents in 22% of cases. The first report of acute pancreatitis attributed to hemobilia came in 1975 as a complication of a percutaneous transhepatic cholangiogram. Management of hemobilia involves careful observation and early consultation with the interventional radiologist. The technique of choice is superselective transcatheter embolization using metallic coils with polyvinyl alcohol beads. The success rate is approximately 95% and it avoids hepatic artery ligation. Fortunately, in our patient, there was spontaneous cessation of bleeding and follow-up revealed no further episodes of bleeding.