Biliary Bleeding Research Articles

One case of biliary duct hemorrhage due to pancreatic pseudoaneurysm

病人,女、67岁,因间歇性排柏油样大便9个月入院.9个月前出现排柏油样大便,每次发作前约1h腹部持续性轻度胀痛伴眩晕,每日柏油样大便约1200g,持续3～5d,无呕吐、巩膜黄染及发热,经输血及药物对症治疗后症状缓解,上述症状间隔约4周反复发作.

MR imaging of hepatocellular carcinomas with biliary tumor thrombi

We retrospectively evaluate the MR imaging findings of hepatocellular carcinomas (HCC) with biliary tumor thrombi. MR imaging was performed on six patients presenting with obstructive jaundice and/or biliary hemorrhage. T1-weighted images, T2-weighted images, MR cholangiopancreatography (MRCP), and dynamic MR images were obtained. Duodenal endoscopy was performed on all cases and hepatic resection on two cases. HCCs were 1.8-10 cm in diameter (mean 5.8 cm). Biliary tumor thrombi were detected in all patients on MR imaging. Tumor thrombi showed hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and contrast enhancement on the early phase of dynamic MR images. MRCP showed intrahepatic bile duct dilatation in all cases. Biliary hemorrhage was clearly depicted by MR images in five cases and showed hyperintensity on T1-weighted images and hyperintensity or hypointensity on T2-weighted images. Biliary hemorrhage was confirmed by endoscopy in two cases. Portal vein thrombi were also associated in five of six patients. Pathologically, tumor thrombi of HCCs were demonstrated in two patients who underwent hepatic resection. In conclusion, MR imaging is useful for the diagnosis of biliary tumor thrombi from HCC and for evaluating the extension of thrombi and biliary hemorrhage.

Hepatic infarction following selective hepatic artery embolization with microcoils for iatrogenic biliary hemorrhage.

Purpose: The aim of this study was to explore the relation of collateral filling to ischemic or infarcted liver following selective embolization of hepatic artery with microcoils in patients with iatrogenic hemobilia. Methods: We performed retrospective analysis of clinical outcomes and post-embolization angiograms in eight patients (mean age of 66 years) studied over the last 7 years. Hemobilia occurred after percutaneous biliary drainage (n = 5) and percutaneous hepatic biopsy (n = 3). Causes of bleeding were pseudoaneurysm (n = 6), arterial laceration (n = 1), and direct hepatic artery-to-biliary duct fistula (n = 1). We placed microcoils in the subsegmental (n = 4) or segmental branch (n = 2), or both branches (n = 2), distal and proximal to the bleeding point. Results: We obtained complete hemostasis in all patients (100%). Four patients had no hepatic infarction after embolization. Normal filling of the distal part of the embolized branch through collaterals was seen on post-embolization films. Four patients with no collateral filling experienced liver infarction in the area corresponding to embolized branch. One patient with severe portal stenosis died of hepatic failure. Conclusion: Hepatic infarction is related to lack of immediate collateral flow.

Biliary complications in adult living donor liver transplantation with duct-to-duct hepaticocholedochostomy or Roux-en-Y hepaticojejunostomy biliary reconstruction

Background. The aim of this study was to compare the incidence of biliary complications after adult living donor liver transplantation (ALDLT) with Roux-en-Y hepaticojejunostomy (R-Y HJ) or duct-to-duct hepaticocholedochostomy (D-D HC). Methods. Biliary complications were reviewed in 20 consecutive ALDLT recipients surviving more than 1 month, including 10 patients who underwent R-Y HJ and 10 patients who underwent D-D HC reconstructions. Results. Ten biliary complications were seen in 8 patients (40%) from the study group. Specifically, 1 case of biliary leakage and 1 case of biliary hemorrhage were observed in the R-Y HJ group (20%), and 2 biliary leakages, 4 biliary strictures, and 2 C-tube related biliary leakages were seen in 6 patients from the D-D HC group (60%). Three of the 5 patients (60%) who underwent right lobe graft ALDLTs experienced biliary stricture. All cases of biliary leakage and biliary hemorrhage were stopped spontaneously by continuous drainage. Three patients in the D-D HC group with anastomotic strictures were successfully treated with percutaneous interventions. Only 1 patient with anastomotic stricture in the D-D HC group with left lobe graft required intrahepatic R-Y HJ reanastomosis. Two cases of C-tube related biliary leakages were treated with endoscopic management. Conclusions. Biliary complications such as anastomotic strictures were common in the D-D HC group rather than in the R-Y HJ group. D-D HC reconstruction should be applied cautiously, especially in the right lobe graft ALDLT cases. (Surgery 2002;132:48-56.)

肝動脈塞栓術にて止血しえたPTCD後胆道出血の1例

肝動脈塞栓術にて止血しえたPTCD後胆道出血の1例

4643 A prospective randomized study of “covered” vs “uncovered” metallic stent for distal malignant biliary obstruction.

Purpose: This study was undertaken to determine the efficacy of polyurethane covered metallic stent in the treatment of patients with distal malignant biliary obstruction. Patients and Methods: From August 1998 to October 1999, we enrolled consecutive 50 patients with irresectable biliary malignancy of common bile duct. They were randomly assigned to polyurethane covered Diamond stent group (25) or original Diamond stent group (25). The prosthesis were implanted endoscopically. Stent patency represented from stent insertion to its occlusion or patient death. Cumulative stent patency and patient survival were estimated according to Kaplan-Meier analysis, supplemented by the log-rank test. Results: There was no significant difference between groups in patient survival. Effective biliary decompression was achieved in all patients initially. The stent patency rates at 3, 6, and 12 months were 100%, 83%, and 83% in the covered group, and 77%, 69%, and 52% in the uncovered group (p=0.055) respectively. Stent occlusion occurred in 1 patient (4%) in the covered group, and in 7 patients (28%) in the uncovered group, respectively. The cause of covered stent occulusion was tumor overgrowth over the tips of the metallic stent. On the other hand, the causes of occlusion in the uncovered group consisted of tumor ingrowth through the stent meshes in 5, tumor overgrowth in 1 and unknown cause in 1. Acute cholecystitis in 1 and mild pancreatitis in 3 occurred in the covered group. Percutaneously drainage was needed for management of cholecystitis. Pancreatitis conservatively improved. In the uncovered group, those complications did not occur. However, biliary bleeding in 1 occurred in uncovered group. Abdominal arteriography showed pseudoaneurysm in common bile duct and transcatheter arterial embolization with gelfoam was performed. Conclusions: Covered Diamond stent showed higher patency rates than the uncovered Diamond stent. Polyurethane cover may be effective to prevent against tumor ingrowth. However, this study is preliminary in nature and further investigations will be needed. Purpose: This study was undertaken to determine the efficacy of polyurethane covered metallic stent in the treatment of patients with distal malignant biliary obstruction. Patients and Methods: From August 1998 to October 1999, we enrolled consecutive 50 patients with irresectable biliary malignancy of common bile duct. They were randomly assigned to polyurethane covered Diamond stent group (25) or original Diamond stent group (25). The prosthesis were implanted endoscopically. Stent patency represented from stent insertion to its occlusion or patient death. Cumulative stent patency and patient survival were estimated according to Kaplan-Meier analysis, supplemented by the log-rank test. Results: There was no significant difference between groups in patient survival. Effective biliary decompression was achieved in all patients initially. The stent patency rates at 3, 6, and 12 months were 100%, 83%, and 83% in the covered group, and 77%, 69%, and 52% in the uncovered group (p=0.055) respectively. Stent occlusion occurred in 1 patient (4%) in the covered group, and in 7 patients (28%) in the uncovered group, respectively. The cause of covered stent occulusion was tumor overgrowth over the tips of the metallic stent. On the other hand, the causes of occlusion in the uncovered group consisted of tumor ingrowth through the stent meshes in 5, tumor overgrowth in 1 and unknown cause in 1. Acute cholecystitis in 1 and mild pancreatitis in 3 occurred in the covered group. Percutaneously drainage was needed for management of cholecystitis. Pancreatitis conservatively improved. In the uncovered group, those complications did not occur. However, biliary bleeding in 1 occurred in uncovered group. Abdominal arteriography showed pseudoaneurysm in common bile duct and transcatheter arterial embolization with gelfoam was performed. Conclusions: Covered Diamond stent showed higher patency rates than the uncovered Diamond stent. Polyurethane cover may be effective to prevent against tumor ingrowth. However, this study is preliminary in nature and further investigations will be needed.

Two Cases of Biliary Hemorrhage after Percutaneous Transhepatic Biliary Drainage in Which Transcatheter Arterial Embolization Was Effective.

Patient No. 1 was a 66-year-old male who was diagnosed as having cancer of the caput pancreatis, and underwent percutaneous transhepatic biliary drainage (PTBD). Since the tube slipped out, percutaneous transhepatic gallbladder drainage (PTGBD) was performed. After PTGBD, biliary hemorrhage was observed for two to three days, then hemorrhage disappeared and bile flowed smoothly. Since the tube was likely to slip out, the tube was replaced. After replacement of the tube, biliary hemorrhage was noted for two to three days, then spontaneously subsided again. After icterus was reduced, pancreatoduodenectomy was performed. During surgery, a number of massive blood clots were noted in the bile duct. The PTGBD tube was removed, and a transjejunal tube was placed. On the 11th day after the surgery, hemorrhage occurred in the bile duct tube, and the patient went into shock. Emergency abdominal angiography was performed. A false aneurysm was detected in A6 and embolized using a microcoil. After transcatheter arterial embolization (TAE), hemorrhage stopped, and the patient was discharged. Patient No. 2 was a 68-year-old male who was diagnosed as having cholelithiasis and underwent PTBD. On the 21st day after PTBD, biliary hemorrhage occurred and the patient fell in shock status. Emergency abdominal angiography was performed. A false aneurysm was detected in A3 and embolized using a microcoil. After TAE, cholangioscopic lithectomy was performed and the disease alleviated. Thereafter the patient was discharged. It is necessary to consider false aneurysm when biliary hemorrhage occurs after PT(G)BD.

Endoscopic local spray of Galla Chinensis compound solution in treating biliary hemorrhage

Biliary hemorrhage often occurs in the treatment of cholelithiasis. A small amount of bleeding can affect the implementation and therapeutic effect of the treatment, while hemorrhage in large amount can incur severe results. Western medicine used in treating biliary hemorrhage is far from satisfactory in effect, so how to prevent and treat it is an important problem in the treatment of cholelithiasis. In recent five years, in our hospital, we have adopted duodenoendoscopy or mother-baby biliary endoscopy for location of hemorrhage accompanied by local spray of traditional Chinese medicine Galla Chinensis in treating biliary hemorrhage and have gained good results.

Omental packing for the transected surface remnant liver after major hepatectomy

To avoid intraabdominal abscess and biliary fistula, which may lengthen hospital stay or result in lethal complications after major hepatic resection, it is important to control postoperative bleeding and bile leakage. We employed a technique for preventing postoperative bleeding and bile leakage, using omental packing with fibrin glue for the transected surface of the remnant liver after hepatic resection. This procedure was employed in 50 patients who underwent major hepatic resection. There was no postoperative bleeding or biliary fistula, and drain tubes were removed within 5 days in all patients. Omental packing with fibrin glue could be a very useful procedure of preventing postoperative biliary fistula, bleeding, and abscess after major hepatic resection.

The role of radiotherapy in the management of extrahepatic bile duct cancer: An analysis of 145 consecutive patients treated with intraluminal and/or external beam radiotherapy

To determine the feasibility of high dose radiotherapy and to evaluate its role in the management of extrahepatic bile duct (EHBD) cancer. Between 1983 and 1991, 145 consecutive patients with EHBD cancer were treated by low dose rate intraluminal 192Ir irradiation (ILRT) either alone or in combination with external beam radiotherapy (EBRT). Among the primarily irradiated, 77 patients unsuitable for surgical resection, 54 were enrolled in radical radiotherapy, and 23 received palliative radiotherapy. Fifty-nine received postoperative radiotherapy, and the remaining 9 preoperative radiotherapy. The mean radiation dose was 67.8 Gy, ranging from 10 to 135 Gy. Intraluminal 192Ir irradiation was indicated in 103 patients, and 85 of them were combined with EBRT. Expandable metallic biliary endoprosthesis (EMBE) was used in 32 primarily irradiated patients (31 radical and 1 palliative radiotherapy) after the completion of radiotherapy. The 1-, 3-, and 5-year actuarial survival rates for all 145 patients were 55%, 18%, and 10%, for the 54 patients treated by radical radiotherapy (mean 83.1 Gy), 56%, 13%, and 6% [median survival time (MST) 12.4 months], and for the 59 patients receiving postoperative radiotherapy (mean 61.6 Gy), 73%, 31%, and 18% (MST 21.5 months), respectively. Expandable metallic biliary endoprosthesis was useful for the early establishment of an internal bile passage in radically irradiated patients and MST of 14.9 months in these 31 patients was significantly longer than that of 9.3 months in the remaining 23 patients without EMBE placement (p < 0.05). Eighteen patients whose surgical margins were positive in the hepatic side bile duct(s) showed significantly better survival compared with 15 patients whose surgical margins were positive in the adjacent structure(s) (44% vs. 0% survival at 3 years, p < 0.001). No survival benefit was obtained in patients given palliative or preoperative radiotherapy. Gastroduodenal complications increased in those receiving doses of 90 Gy or more, and serious biliary bleeding was experienced in three preoperatively irradiated patients. Complications in other patients was tolerable. High-dose radiotherapy, consisting of ILRT and EBRT, appears to be feasible in the management of EHBD cancer, and it offers a survival advantage for patients not suited for surgical resection and patients with positive margins in the resected end of the hepatic side bile duct. Expandable metallic biliary endoprosthesis assists the internal bile flow and may lengthen survival after high dose radiotherapy.

Tips: the New Kid on the Block. Laberge Jm, Ring Ej, Gordon Rl, Lake Jr, Doherty Mm, Somberg Ka, Roberts Jp, Ascher Nl . Creation of Transjugular Intrahepatic Portosystemic Shunts With the Wallstent Endoprosthesis: Results in 100 Patients. Radiology 1993;187:413-420

ABSTRACT One hundred patients underwent transjugular intrahepatic portosystemic shunt (TIPS) creation for variceal bleeding (n = 94), intractable ascites ( n = 3), hepatorenal syndrome ( n = 2), and preoperative portal decompression ( n = 1). Shunts were completed in 96 patients. Portal vein pressure was reduced from 34.5 mm Hg ± 7.6 (standard deviation) to 24.5 mm Hg ± 6.2; the residual portal vein–hepatic vein gradient was 10.4 mm Hg ± 0.9. Acute variceal bleeding was controlled in 29 of 30 patients. Of the 96 patients who underwent successful TIPS creation, 26 have died and 22 have undergone liver transplantation; the remaining 48 patients have survived an average of 7.6 months. Variceal bleeding recurred in 10 patients. Fifteen patients developed shunt stenosis ( n = 6) or occlusion ( n = 9). Patency was reestablished in eight of the nine occluded shunts. Seventeen patients developed new or worsened encephalopathy. The authors conclude that TIPS creation is an effective and reliable means of lowering portal pressure and controlling variceal bleeding, particularly in patients with acute variceal bleeding unresponsive to sclerotherapy and patients with chronic variceal bleeding before liver transplantation. Background. Transjugular placement of an intrahepatic stent is a new technique to establish a portosystemic shunt for treatment of portal hypertension. A puncture needle is advanced in a catheter through the inferior vena cava into a hepatic vein; then an intrahepatic branch of the portal vein is punctured and an expandable stent of metallic mesh is implanted to establish the shunt. Methods. We attempted the stent–shunt procedure in 100 of 112 consecutive patients with variceal bleeding due to cirrhosis, who were then followed for a mean (± SD) of 12 ± 6 months. Of the 100 patients, 22 had Child–Pugh class C cirrhosis, 10 were treated on an emergency basis, and 68 had alcoholic cirrhosis. The shunt was established with use of Palmaz stents expanded to 8 to 12 mm in diameter. Results: Technical success was achieved in 93 percent of the patients. The mean (± SD) time for the procedure was 1.2 ± 0.3 hours. The shunt reduced the portal venous pressure gradient by 57 percent. Major complications were hemorrhage (intraabdominal bleeding in six patients, biliary bleeding in four, and bleeding in the liver capsule in three) and migration of the stent into the pulmonary artery (in two patients). At follow–up, stenosis of the shunt was evident in 21 patients and occlusion in 10 patients; 10 of these 31 patients had variceal rebleeding. Stenoses and occlusions of the shunt were all treated successfully by redilation, thrombolysis, or implantation of an additional stent. Hepatic encephalopathy (stages I to III) developed in 25 percent of the patients. The proportion of patients with shunts who remained free of variceal rebleeding was 92 percent at six months and 82 percent at one year. The 30–day mortality was 3 percent. The cumulative one–year survival was 85 percent. Conclusions. These results suggest that the transjugular placement of an intrahepatic portosystemic stent is an effective and safe treatment for variceal hemorrhage in patients with portal hypertension due to cirrhosis. (N Engl J Med 1994;330:165-71).

The Transjugular Intrahepatic Portosystemic Stent-Shunt Procedure for Variceal Bleeding

Transjugular placement of an intrahepatic stent is a new technique to establish a portosystemic shunt for treatment of portal hypertension. A puncture needle is advanced in a catheter through the inferior vena cava into a hepatic vein; then an intrahepatic branch of the portal vein is punctured and an expandable stent of metallic mesh is implanted to establish the shunt. We attempted the stent-shunt procedure in 100 of 112 consecutive patients with variceal bleeding due to cirrhosis, who were then followed for a mean (+/- SD) of 12 +/- 6 months. Of the 100 patients, 22 had Child-Pugh class C cirrhosis, 10 were treated on an emergency basis, and 68 had alcoholic cirrhosis. The shunt was established with use of Palmaz stents expanded to 8 to 12 mm in diameter. Technical success was achieved in 93 percent of the patients. The mean (+/- SD) time for the procedure was 1.2 +/- 0.3 hours. The shunt reduced the portal venous pressure gradient by 57 percent. Major complications were hemorrhage (intraabdominal bleeding in six patients, biliary bleeding in four, and bleeding in the liver capsule in three) and migration of the stent into the pulmonary artery (in two patients). At follow-up, stenosis of the shunt was evident in 21 patients and occlusion in 10 patients; 10 of these 31 patients had variceal rebleeding. Stenoses and occlusions of the shunt were all treated successfully by redilation, thrombolysis, or implantation of an additional stent. Hepatic encephalopathy (stages I to III) developed in 25 percent of the patients. The proportion of patients with shunts who remained free of variceal rebleeding was 92 percent at six months and 82 percent at one year. The 30-day mortality was 3 percent. The cumulative one-year survival was 85 percent. These results suggest that the transjugular placement of an intrahepatic portosystemic stent is an effective and safe treatment for variceal hemorrhage in patients with portal hypertension due to cirrhosis.

Pathophysiology of ovine fascioliasis: The influence of dietary protein and iron on the erythrokinetics of sheep experimentally infected with Fasciola hepatica

Worm-free sheep were fed diets with a high or low protein and iron content and infected with 1,000 F. hepatica metacercariae. The adult fluke burdens of the sheep on each diet were similar, but animals on the poorer plane of nutrition developed an earlier and ultimately more severe anaemia and as a result had to be necropsied earlier. By measuring the attendant changes in blood volume and erythrokinetics, it was found that the underlying cause of the anaemia in all animals was a combination of haemodilution, intra-hepatic and biliary haemorrhage, and its earlier appearance and faster development in the poorer-fed group was a refelection of the earlier onset of these changes in association with a faster rate of fluke migration. The ultimate degree of anaemia was not related to the severity of biliary haemorrhage, but rather to the animals' erythropoietic capacity. This was substantially lower in the sheep maintained on the poorer diet, which unlike their better-fed counterparts, became iron deficient by virtue of their inability to replace from the diet iron lost in the faeces as a result of haemorrhage. It was concluded that this difference was primarily a reflection of the better appetite and hence iron intake of the supplemented sheep, but differences in the efficiency of dietary iron utilization, possibly related to protein intake, may also have been involved. In a further experiment involving sheep infected with 600 metacercariae, there was no evidence of haemodilution. When provided with a diet of high protein and iron content, these animals were able to maintain constant, albeit reduced PCV values in the face of substantial biliary haemorrhage. However, when switched to an inferior diet, the same degree of haemorrhage produced a sharp fall in PCV, suggesting that erythropoiesis was adversely affected by reduced protein and iron intake.

Obstructive jaundice in macroglobulinemia.

AbstractDysproteinemias usually present with bleeding from mucosal membranes. It has never been reported to cause hemobilia. We are reporting two cases of macroglobulinemia that presented with obstructive jaundice secondary to hemobilia. Although we are not sure of the source of the hemobilia, cholecystectomy and removal of the blood clots from the common bile duct resulted in alleviation of jaundice and no further gross biliary bleeding. There was no recurrence of jaundice in either case in one year and eight months respectively.

Ulceration of the Common Bile Duct as a Cause of Hemobilia

Summary A case of massive spontaneous biliary hemorrhage due to an ulceration, possibly peptic, of the common bile duct in a patient with a choledochoduodenstomy, is presented and the usefulness of the choledochoscope in the diagnosis of a case of biliary tract bleeding is demonstrated. The pertinent literature on the subject of hemobilia is reviewed.

Hemobilia.

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.