S2112 A Mysterious Case of Recurrent Hemobilia Caused by Veno-Biliary Fistula

Abstract

INTRODUCTION: Hemobilia is a rare but important cause of upper gastrointestinal bleeding caused usually by fistula formation between the hepatic artery and intrahepatic or extra-hepatic biliary system. It is associated with a high mortality rate of 25%. We present a case of recurrent haemobilia from a portal venous source which is exceedingly rare. CASE DESCRIPTION/METHODS: A 71-year-old male with a past medical history of decompensated alcoholic cirrhosis, grade II esophageal varices (EV), recent diagnosis of HCC presented with hematemesis and melena. Of note, the patient was admitted two other times for upper gastrointestinal bleeding after he underwent TACE. On exam his heart rate was 104 beats/minute, blood pressure was 100/90 mm Hg. Lab findings showed a Hb of 7.1 g/dL with a Hct of 23.7%, ALP of 180 units/L, AST of 18 units/L, ALT of 28 units/L, Total bilirubin of 0.6 mg/dL, lactic acid of 2.7 mmol/L. A suboptimal upper gastrointestinal endoscopy (EGD) on admission showed old blood in the gastric antrum and duodenum and grade I EV with no stigmata of bleeding. An EGD performed 48 hours later showed non-bleeding grade I EV and intermittent active haemobilia in the papillary area. CT angiography (CTA) with arterial and venous phase showed no active hemorrhage which was deemed secondary to the intermittent nature of the bleed. The patient underwent hepatic arteriogram and segment 8 was empirically gelfoam embolized. Even post hepatic artery embolization, the patient had multiple admissions with melena and drop in hemoglobin. At this point, a fistula between portal vein and biliary tract was suspected and a TIPS procedure was performed. The patient had no further episode of bleeding after the procedure and his hemoglobin has been stable and improved to 12 g/dL. DISCUSSION: Several case reports thus far, describe hemobilia due to fistula between an arterial source and bile ducts. However, hemobilia can also emanate from venous blood flow, which in contrast tends to be of lower volume or self-limited (except in cases of portal hypertension, in which case it may be of larger volume and/or persistent). CTA is used in the diagnosis, but angiogram is still considered gold standard. Treatment strategies for an arterial source such as trans-arterial embolization and vascular stenting are well-established but the literature on management of hemobilia from a venous source is sparse. Hemobilia in our patient was controlled with TIPS which has not been previously described.