S1513 Liver Biopsy Leading to Hemobilia Complicated by Cholangitis, Biliary Pancreatitis, and Massive Gastrointestinal Hemorrhage

Abstract

INTRODUCTION: Percutaneous liver biopsies (PLB) are performed routinely to investigate liver masses, unexplained hepatomegaly or abnormal liver chemistries and are relatively safe in the absence of coagulopathy. Here, we present a rare complication of PLB: arterio-biliary fistula presenting with delayed onset of hemobilia, massive gastrointestinal hemorrhage, acute cholangitis and acute biliary pancreatitis requiring emergent embolization and antimicrobial therapy. CASE DESCRIPTION/METHODS: A 62-year-old female recently diagnosed primary biliary cholangitis presented with hematemesis, hematochezia and jaundice 1 week after percutaneous liver biopsy. On admission, she was febrile, hypotensive and tachycardic. Physical exam was notable for scleral icterus, jaundice and right upper quadrant abdominal tenderness with voluntary guarding. Rectal exam revealed a large amount of bright red blood. Laboratory data was significant for hemoglobin of 7.7 g/dL from 11.1 g/dL prior to liver biopsy, total bilirubin 7.5 mg/dL (1.0 unconjugated/4.5 conjugated), ALP 587 U/L, GGT 504 U/L, AST 98 U/L, ALT 83 U/L, lipase 3017 U/L. CT angiography of the abdomen showed contrast throughout the proximal hepatic and common bile ducts concerning for active bleeding from an arterio-biliary fistula resulting in hemobilia, moderate biliary dilation, and bowel contents concerning for intraluminal bleeding from the biliary system. She was treated with broad-spectrum antibiotics and successfully resuscitated with IV crystalloids and blood products. She underwent emergent mesenteric angiography with left hepatic artery and arterioportal fistula coil embolization which resulted in hemostasis and rapid normalization of liver chemistries. DISCUSSION: Major gastrointestinal bleeding complications due to iatrogenic arterio-biliary fistula formation after PLB are exceedingly rare, occurring less than 1% of the time due to needle intersection with the portal triad, resulting in epithelialized shunt formation between the hepatic artery and bile duct. This case represents a later presentation of hemobilia, which typically occurs within 24 hours of PLB. The accumulation of blood clots in the biliary tree can lead to life threatening cholangitis and biliary pancreatitis. Early recognition of this complication is essential as urgent embolization and aggressive antimicrobial therapy can lead to a significant reduction in mortality.Figure 1.: CT angiogram abdomen/pelvis: contrast visible in the common hepatic duct.Figure 2.: Pre-embolization: segment 3 branch of hepatic artery.Figure 3.: Post-embolization: segment 3 branch of hepatic artery.