S2227 A Rare Case Report: Spontaneous Hemobilia in a Patient With Cirrhosis

Abstract

INTRODUCTION: Hemobilia is a rare but important cause of gastrointestinal bleeding that can be challenging to diagnose. When present, it is commonly in the setting of recent hepatopancreaticobiliary tract procedures, trauma or malignancy. We report a case of a 62 year old male diagnosed with non-iatrogenic, atraumatic and non-malignant hemobilia. CASE DESCRIPTION/METHODS: A 62 year old male with alcoholic cirrhosis and esophageal varices presented with right upper quadrant pain, jaundice and hematemesis. Physical examination revealed scleral icterus, a mildly tender abdomen and a normal rectal exam. He was hemodynamically stable with WBC 18.5 × 103/µL, lactic acid 11.8 mmol/l, hemoglobin (hb) 7.5 g/dL, total bilirubin 2.8 mg/dL, direct bilirubin 1.7mg/dL, INR 2.2, ALT 32 IU/L, and AST 118 IU/L. Blood cultures grew extended-spectrum beta-lactamase Escherichia coli requiring treatment with Meropenem. Abdominal ultrasound demonstrated ascites, choleilithiasis and common bile duct (CBD) diameter of 0.7cm. On day 3, MRCP demonstrated CBD of 0.7 cm without choledocholithiasis. On hospital Day 7, he underwent Esophagogastroduodenoscopy (EGD) which showed grade II esophageal varices without red whale or white nipple sign. On day 10, the patient had melena with drop in hb from 7.8g/dL to 6.2g/dL.Repeat EGD, colonoscopy and a tagged RBC study did not show an active source of bleeding. On day 19, he had melena again. Repeat EGD showed clotted blood in the second portion of duodenum and ampulla. With the use of side-view ERCP scope, fresh blood was seen coming from the major papilla, suggestive of hemobilia. CT abdomen demonstrated possible pseudoaneurysm of right hepatic artery with fistula to the portal vein. IR-guided angiogram was negative for an arterial pseudoaneurysm of the right hepatic artery. Consideration was given to obtain a CT tri-phase of the liver to evaluate if the source of bleeding was arterial or venous, but given poor prognosis and limited treatment options, the patient decided to forgo further evaluation. DISCUSSION: Only a few cases of hemobilia are described in literature in cirrhotic patients. Our patient presented with classic Quincke’s triad of right upper quadrant pain, jaundice and GI bleed, normally seen in only 25-30% of patients with hemobilia. In any patient presenting with GI bleed, hemobilia should be on the differential as it can be easily missed. If the source of bleeding cannot be identified it can be fruitful to use different endoscopic techniques as we did with our patient.Figure 1.: Using a side-viewing ERCP scope, there is fresh blood seen coming out of the major papilla.Figure 2.: This figure demonstrates a rounded region of hyperdensity which is adjacent to the left base of the gallbladder directly anterior to the right hepatic artery. It is favored to represent a pseudoaneurysm with fistula to the portal vein.