Case Of Hemobilia Research Articles

A challenging case of hemobilia: Endovascular treatment of cystic artery pseudoaneursym secondary to acute cholecystitis

A challenging case of hemobilia: Endovascular treatment of cystic artery pseudoaneursym secondary to acute cholecystitis

Percutaneous transhepatic intraluminal forceps biopsy for patients with biliary stricture after endoscopic retrograde approach failure: a retrospective study.

The etiological diagnosis of biliary stricture remains a clinical challenge. Currently, endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary biopsy is the most commonly used technique. This retrospective study aimed to evaluate the clinical value of percutaneous transhepatic intraluminal forceps biopsy (TIFB) in patients with biliary stricture after ERCP failure. The clinical data of 240 consecutive patients with biliary strictures who sought further etiologic diagnosis at our center between April 2014 and January 2020 were collected. After the exclusion of 197 patients who underwent ERCP-guided biopsy, 43 patients who received TIFB after ERCP failure were included in the study. The primary outcomes were technical success, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy. Secondary outcomes included procedure duration, radiation exposure, liver function [total bilirubin (TB), direct bilirubin (DB), γ-glutamyl transferase (GGT), alkaline phosphatase (ALP), alanine aminotransferase (ALT), and aspartate aminotransferase (AST)] preoperatively and at 2 weeks postoperatively, and complications. The technical success rate of TIFB was 100%. The diagnostic sensitivity, specificity, accuracy, PPV, and NPV of TIFB were 82.35%, 100%, 86.05%, 100%, and 60%, respectively. The accuracy of TIFB was significantly higher for cases with suspicious biliary tract invasion on imaging and intrabiliary malignant origin than it did for cases with no suspicious biliary tract invasion on imaging or extrabiliary malignant origin (P=0.007 and P=0.003, respectively). Only intrabiliary malignant origin (P=0.02) was an independent contributing factor for a true positive result in TIFB diagnosis. The mean procedure duration was 19.3 minutes and the mean radiation exposure was 315.6 mGy. All liver function markers were significantly reduced after 2 weeks (all P<0.001). Three (6.97%) complications occurred, including 1 (2.33%) case of cholangitis and 2 (4.65%) cases of hemobilia. Percutaneous TIFB is an effective method with high sensitivity and accuracy for the etiological diagnosis of biliary stricture after ERCP failure.

A case of hemobilia with hemorrhagic shock; successfully performed emergency ERCP to identify bleeding point by stone retrieval balloon and to achieve hemostasis by placing fully-covered metal stent

A case of hemobilia with hemorrhagic shock; successfully performed emergency ERCP to identify bleeding point by stone retrieval balloon and to achieve hemostasis by placing fully-covered metal stent

A case of hemobilia caused by pancreatic metastasis of renal cell carcinoma treated with a covered metallic stent

We present the case of an 86-year-old man who had undergone left nephrectomy for renal cell carcinoma (clear cell carcinoma) 22 years ago. He visited the emergency department complaining of right hypochondrial pain and fever. He was eventually diagnosed with acute cholangitis. Abdominal contrast-enhanced computed tomography showed multiple tumors in the pancreas. The tumor in the pancreatic head obstructed the distal bile duct. Endoscopic retrograde cholangiopancreatography detected bloody bile juice flowing from the papilla of Vater. Therefore, he was diagnosed with hemobilia. Cholangiography showed extrinsic compression of the distal bile duct; a 6 Fr endoscopic nasobiliary drainage tube was placed. Endoscopic ultrasound showed that the pancreas contained multiple well-defined hypoechoic masses. Endoscopic ultrasound-guided fine-needle aspiration was performed using a 22 G needle. Pathological examination revealed clear cell carcinoma, and the final diagnosis was pancreatic metastasis of renal cell carcinoma (RCC) causing hemobilia. A partially covered metallic stent was placed in the distal bile duct. Consequently, hemobilia and cholangitis were resolved.

S1581 Hemobilia From an Unlikely Culprit: A Case of a Ruptured Pseudoaneurysm

Introduction: Hemobilia, or bleeding from the hepatobiliary tract, is a rare cause of GI bleeding and jaundice. Most cases of hemobilia are iatrogenic secondary to hepatobiliary interventions, however, trauma and malignancy also represent a major source. We present a case of hemobilia secondary to a hepatic artery pseudoaneurysm, in the setting of acute cholecystitis and metastatic liver disease. Case Description/Methods: A 67-year-old man presented with 3 days of RUQ abdominal pain radiating to the epigastrium. On arrival, he was tachycardic, afebrile, and normotensive. He had RUQ tenderness and icterus. Laboratory findings were significant for leukocytosis, anemia, transaminitis, elevated alkaline phosphatase, and hyperbilirubinemia. An ultrasound of the abdomen was suggestive of calculous cholecystitis and a dilated CBD of 0.8 cm. He underwent a EUS which revealed a dilated CBD with heterogeneous mater. An ERCP showed altered blood at the ampulla. A sphincterotomy was performed and a large blood clot was extracted from the CBD via balloon sweeps. Two plastic stents were then placed for drainage after which brisk arterial bleeding was noted. Urgent angiography revealed evidence of a ruptured pseudoaneurysm arising from the anterior division of the right hepatic artery near segment 8 of the liver. Successful coil embolization was performed. A CT scan of the abdomen revealed rectal thickening and hypoenhancing liver lesions suggestive of metastatic disease. On flexible sigmoidoscopy, a fungating, partially obstructing rectal mass was seen, biopsies of which were positive for invasive adenocarcinoma. Cholecystitis confirmed on HIDA scan was treated conservatively with antibiotics. He was subsequently discharged and started on chemotherapy as an outpatient. He is now planned for a repeat ERCP with stent exchange. Discussion: Hemobilia can masquerade as biliary stones on EUS. Management includes early diagnosis, identification of the source of bleeding, achieving hemostasis, and relieving the obstruction. Transcatheter arterial embolization is preferred if there are any signs of arterial extravasation. Biliary obstruction can be relieved with ERCP and stent placement. In the presence of underlying malignancy, infiltrative disease and its surrounding vascular friability are often implicated. However, a benign etiology should not be overlooked as illustrated in our case. Cholecystitis leading to severe inflammation of the gallbladder bed can cause adjacent arterial wall degeneration and pseudoaneurysm formation.Figure 1.: (A) Superselective catheterization of the right hepatic artery and angiography demonstrating evidence of 1.2 x 0.9 cm pseudoaneurysm/contained perforation, arising from a suspected proximal segment 8 arterial branch. (B) Endoscopic ultrasound demonstrating a dilated common bile duct up to 12 mm, filled with heterogeneous material. The gallbladder wall appears thickened. (C) CT abdomen with contrast showing multiple hypoenhancing liver lesions within the right and left lobes. Surgical coils within the right lobe of the liver consistent with a recent embolization procedure. Common bile duct stent in place, and small foci of pneumobilia. (D) ERCP images showing blood clots protruding from the ampulla. After balloon sweeps and sphincterotomy, two 10 Fr by 7 cm plastic stents were placed in the CBD.Table 1.: Laboratory Values from Admission and Discharge day.

S1672 A Rare Case of Hemobilia From a Large Hepatic Artery Pseudoaneurysm Caused by CT-Guided Liver Biopsy

S1672 A Rare Case of Hemobilia From a Large Hepatic Artery Pseudoaneurysm Caused by CT-Guided Liver Biopsy

An iodine-125 seed strand combined with a metal stent versus a metal stent alone for obstructive jaundice caused by pancreatic ductal adenocarcinoma

PurposeThe purpose of this study was to assess the efficacy of an iodine-125 (125I) seed strand combined with a metal stent compared with a metal stent for treatment of obstructive jaundice caused by pancreatic ductal adenocarcinoma (PDAC). Methods and MaterialsA retrospective analysis was carried out of patients who were referred to Shanghai Zhongshan Hospital of Fudan University with a diagnosis of PDAC between January 1, 2010 and January 31, 2019. A total of 110 consecutive patients with obstructive jaundice caused by PDAC were divided into the iodine-125 seed strand combined with a metal stent group (Group A = 48) and the metal stent group (Group B = 62). The primary outcome was stent obstruction–free survival time, and secondary outcomes were overall survival and complications. ResultsThe median stent obstruction–free survival time was 133.0 (95% confidence interval (CI): 166.093–149.907) days, and the median overall survival was 212.0 (95% CI: 187.183–236.817) days in all patients. Median stent obstruction–free survival time was 175 days (95% CI 103.165–246.835 days) in Group A versus 120 days (95% CI 87.475–152.525 days) in Group B (p = 0.035). A lower Eastern Cooperative Oncology Group (ECOG) score (p = 0. 000) and iodine-125 seed strand combined with metal stent implantation (p = 0.008) were associated with a longer stent obstruction–free survival time. Obstruction length (p = 0.083), ECOG score (p = 0.000), and iodine-125 seeds (p = 0.037) might have potential impact on stent obstruction–free survival time and were included for multivariable analysis using the Cox proportional hazards model. Stent restenosis was observed in 18.8% (9/48) of patients in Group A and 54.8% (34/62) in Group B, respectively. There was no significant difference in median survival between Group A and Group B (p = 0.409). The median survival in Group A was 209 days (95% CI 150.750–267.250) and 202 days (95% CI 190.624–233.376) in Group B. The median survival of patients with a lower ECOG score was better than that of patients with a higher ECOG score (267 days vs 132 days, p = 0.000). The Grade 3 or 4 complications occurred in 4 (8.3%) of the 48 patients in Group A (one case of hemobilia, one case of liver abscess, two cases of choleperitonitis) and in 5 (8.1%) of the 62 patients in Group B (one case of hemobilia, two cases of liver abscess, two cases of choleperitonitis) (p = 0.972). ConclusionsImplantation of an iodine-125 seed strand combined with a metal stent provides longer obstruction-free survival time compared with a metal stent in patients with obstructive jaundice caused by PDAC. It seems reasonable to choose an iodine-125 seed strand combined with a metal stent as a treatment for these patients.

S1466 Blood Is Thicker Than Water...and Bile: A Rare Case of Hemobilia

INTRODUCTION: There are a myriad of etiologies concerning upper gastrointestinal bleeding (UGIB). The common culprits include peptic ulcer disease, erosive esophagitis, and varices. However, if we delve deeper into literature, way deeper, we find a more elusive source for the ever-so common UGIB: hemobilia. Hemobilia is bleeding arising from the biliary tract. Over 50% of cases are secondary to iatrogenic causes. This can be attributed to the prevalence of interventional procedures. Here, we present a 65-year-old male with a recently diagnosed history of hepatocellular carcinoma (HCC), who presented with a sudden elevation in liver enzymes and bilirubin, and subsequently was found to have hemobilia. CASE DESCRIPTION/METHODS: Our patient is a 65-year old male with past medical history significant for decompensated cirrhosis of unknown etiology and HCC who presented to the emergency room for a CHF exacerbation. Two days into his hospital stay, our patient's lab work revealed acute transaminitis and hyperbilirubinemia. A subsequent magnetic resonance cholangiopancreatography (MRCP) was performed which showed a questionable filling defect in the mid common bile duct (CBD), unchanged mass in the right lobe of liver, and a filling defect seen within the portal vein concerning for tumor thrombus. Total bilirubin peaked at 13.1 mg/dL. ERCP was performed with balloon sweep of the CBD and removal of large amount of blood clots indicating hemobilia. One 10 mm diameter covered metal stent was placed into the CBD. It was determined that the most likely etiology of the hemobilia was tumor invasion of the biliary tree producing a spontaneous hemorrhage. DISCUSSION: “En garde!” Imagination dictates that this French phrase meaning “On your guard!” could have been associated with the first case of hemobilia. Hemobilia was first described in 1654 by Francis Glisson when he described a liver laceration a man received during a duel. Hemobilia is usually described by Quincke's triad of upper abdominal pain, jaundice, and UGIB. However, this classic presentation is only observed in approximately 35% of cases. Our patient, with a known history of HCC, initially did not present with any of these symptoms-the only alarm finding was sudden transaminitis. As stated earlier, it is iatrogenic causes that predominantly lead to hemobilia. On the other hand, the most common cause of spontaneous hemobilia is hepatobiliary malignancy. HCC is the most common malignancy associated with hemobilia, with cholangiocarcinoma being a close second.Figure 1.: Shows hemobilia prior to intervention.Figure 2.: Shows large blood clot being swept out of CBD.Figure 3.: Shows blood and bile flowing through covered metal stent.

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

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.

S3523 Rare Complication of Liver Biopsy

INTRODUCTION: Bleeding from the hepatobiliary tract is an unusual cause of the acute upper gastrointestinal bleed. Liver biopsy is deemed a safe and highly effective procedure to diagnose numerous liver conditions. Since its introduction at the end of the 19th century, modern imaging methods, special needles, and clinical experience have significantly reduced the rate of complications associated with liver biopsy. Hemoperitoneum, sub-capsular hematoma, pneumothorax, sepsis, and haemobilia are rare complications associated with liver biopsy. We are presenting a case of haemobilia, which resulted as a complication of liver biopsy and its management. CASE DESCRIPTION/METHODS: A 62-year-old male presented after an episode of hematemesis, severe right upper abdominal pain, jaundice, and melena after transjugular liver biopsy for evaluation of autoimmune hepatitis. Abdominal ultrasound showed dilated common bile duct (CBD), indicating biliary obstruction. Upper endoscopy, however, showed no signs of ongoing or old bleeding. These findings were followed by endoscopic retrograde cholangiopancreatography (ERCP) with discovery of blood clots in the CBD, revealing the diagnosis of haemobilia. The blood clots were removed and followed by placement of a plastic stent in the CBD. The patient, however, underwent a repeat ERCP with replacement of CBD stent as he continues to have melena requiring multiple blood transfusions. After the deployment of metal stent, patient's abdominal pain started to improve and his hemoglobin level stabilized. The third ERCP was performed 4 days later, which confirmed the resolution of haemobilia. The patient's symptoms continued to improve and was discharged after 29 days of hospitalization. DISCUSSION: Percutaneous or transjugular liver biopsies are performed very frequently for evaluation of causes of liver conditions in a safe and effective way. Complications associated with liver biopsy are uncommon, but severe complications do occur. Our case illustrates a distinctive way of managing such rare complication with advanced techniques like biliary stenting.

Hemobilia-a rare complication after laparoscopic cholecystectomy-

BackgroundBiliary bleeding is a condition reported by Sandblom as hemobilia. The most common cause of hemobilia is iatrogenicity. But it has also been reported as a rare complication after laparoscopic cholecystectomy (LC).Case presentationA man in his 60s underwent a LC. He was taking a direct Xa inhibitor for paroxysmal atrial fibrillation (pAf) and had a history of thrombectomy. There was variation in the bifurcation of the hepatic artery and cystic artery. The right hepatic artery branches from the common hepatic artery by itself, and the cystic artery is double. He complained of right upper quadrant pain, nausea, and vomiting on the third postoperative day (3POD). Non-contrast computed tomography (CT) showed that a high absorption area was found to fill the common bile duct. Contrast CT showed no pseudoaneurysm formation. Ultimately, he was diagnosed with postoperative hemobilia. Angiographic examination selective for the cystic artery branching from the middle hepatic artery revealed leakage of the contrast agent and a micro-pseudoaneurysm.ConclusionsWe encountered a case of hemobilia after LC. In this case, it was presumed that in addition to the chronic inflammatory changes of the gallbladder wall, extraordinary bifurcation of the hepatic artery and the cystic arteries and easy bleeding due to resumption of a direct Xa inhibitor synergistically caused a micro-pseudoaneurysm and postoperative hemobilia. It was difficult to identify the cause of hemobilia by contrast CT alone. Angiographic examination was useful for identifying and treating the causative artery and needs to perform aggressively.

Hemobilia: Historical overview, clinical update, and current practices.

Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosisof hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.

Two cases of hemobilia caused by a rupture of pseudoaneurysm

Two cases of hemobilia caused by a rupture of pseudoaneurysm

Hepatocellular Carcinoma Presenting as Hemobilia: A Case Report

Introduction Hemobilia from hepatocellular carcinoma (HCC) is rare and is usually noted in established cases of HCC after an invasive procedure. We describe an unusual case of hemobilia causing obstructive jaundice, cholangitis and pancreatitis with subsequent work up revealing HCC. Case report A 61 yr old Hispanic M presented with one day of abdominal pain, N/V, subjective fevers. His PMH was significant for recent right portal vein thrombosis (PVT) and E coli sepsis for which he was on anticoagulation and oral antibiotics. His vitals were stable. Labs were significant for WBC 15 k/μL, Total bilirubin 15.2 mg/dL (direct bilirubin 12 mg/dl), ALP 704 U/L, lipase 3463 U/L, INR 2.7 and Hgb 11.8 g/dL. CT revealed persistence of right PVT, peripancreatic edema and fluid, and intra and extrahepatic biliary dilation with CBD measuring 17mm with hyperdense material within it suspicious for blood (Fig. 1). ERCP with biliary sphincterotomy was performed due to obstructive jaundice and suspected cholangitis. A large and long organized clot was swept from the CBD confirming hemobilia. A 10 mm x 8 cm covered metal stent was placed in the CBD for tamponade effect and to relieve obstruction. A CT angiogram showed a focus of hypervascularity measuring 19 mm on arterial phase within hepatic segment 5 suspicious for a pseudoaneurysm. A subsequent arteriogram showed the right hepatic lesion to be a hypervascular lesion concerning for HCC with no apparent pseudoaneurysm or active extravasation (Fig. 2). Serum AFP level was elevated at 653 ng/ml. Patient was diagnosed with HCC, which likely was the cause of his right PVT and subsequent hemobilia in the setting of anticoagulation. Patient's hospital course was otherwise unremarkable. During subsequent follow up, he has continued to do well. He has declined liver transplant evaluation and is being evaluated for either transarterial chemoembolization or radiofrequency ablation.2271_A Figure 1. Computerized tomography showing hyperdense material within dilated CBD2271_B Figure 2. A hypervascular lesion right hepatic lobe on arteriogramDiscussion HCC related hemobilia is rare and is usually reported in established HCC patients undergoing hepatobiliary procedures. In our case, patient presented with complication related to hemobilia with subsequent diagnosis of HCC. Bleeding usually stops with supportive therapy alone but in persistent or severe bleeding arterial embolization may be needed. ERCP is warranted when biliary obstruction and its complications are evident. Fully covered metal stents can be effective in achieving hemostasis and relieving obstruction.

Hepatocelluar Carcinoma Invading the Gallbladder - A Rare Cause of Hemobilia

Bleeding from the hepatobiliary tract (hemobilia) is a rare cause of acute upper GI bleed. It should be considered in any patient with recent history of hepatic parenchymal or biliary intervention, angioembolization, blunt abdominal trauma or hepatic malignancy. We describe a rare case of hemobilia due to hepatocellular carcinoma (HCC) invading the gall bladder wall. A 52- year old female with Laennec's cirrhosis complicated by HCC status post transarterial chemoembolization (TACE) presented with black tarry stools, dizziness and abdominal pain. Physical examination was significant for right upper quadrant tenderness to palpation and melanotic stools. Labs were consistent with severe anemia, thrombocytopenia and liver profile derangement. An MRI performed the month prior to admission, demonstrated a 3.1 cm oval-shaped, arterial phase enhancing lesion in the lateral aspect of the right hepatic lobe, suspicious for residual HCC (Fig A). She was aggressively transfused multiple blood products, placed on a proton pump inhibitor and started on octreotide. An emergent EGD was performed which identified blood oozing from the ampulla of vater; consistent with a diagnosis of hemobilia (Fig B). A CTA was negative for active extravasation. The presumed etiology was invasion of the residual HCC into the gall bladder wall given the close proximity identified on MRI. Given her history of TACE and severe liver dysfunction, she was not a candidate for embolization and she was medically managed. First recorded in 1654 by Francis Glisson, hemobilia is an exceedingly rare condition with unknown exact incidence. Traumatic etiology accounts for 40-80 percent of all cases. In patients with HCC, invasion into the blood vessels is a frequent feature, however gallbladder and ductal invasion is widely unrecognized. One study involving 24 patients with HCC was performed to describe the features of intra-biliary duct invasion. 21 percent developed hemobilia; one patient subsequently died from hemorrhagic shock. Approximately one-third of all patients will present with quinke's Triad: acute upper GI bleed (100 percent), biliary colic (70 percent) and jaundice (60 percent). Diagnosis is by visualizing blood from the Ampulla of vater via EGD or ERCP. The best diagnostic and therapeutic intervention is angiography with embolization (success rate > 95 percent). Despite aggressive intervention, severe hemobilia has been shown to have a mortality as high as 25 percent.1950_A Figure 1. A 3.1 cm oval shaped arterial phase enhancing lesion in the lateral aspect of the right hepatic lobe (arrow) suspicious for residual HCC within close proximity of the gall bladder.1950_B Figure 2. EGD oozing from the ampulla of vater (A) and showing blood oozing within the second part of the duodenum (B).

Outcomes of percutaneous transluminal biopsy of biliary lesions using a dedicated forceps system.

Distinction between benign and malignant biliary obstruction is always challenging. To evaluate outcomes of percutaneous transluminal biopsy of biliary strictures using a dedicated forceps system. This prospective, single-center, single-arm study, included 29 consecutive patients (17 men [56.6%]; mean age = 60 ± 9 years), who underwent 30 transluminal biopsies during percutaneous transhepatic biliary drainage (PTBD) due to obstructive jaundice, between September 2014 and January 2017, using a transluminal biliary access and biopsy forceps set. The study's primary efficacy endpoint was technical success and the primary safety endpoint was the procedure-related major complications rate. The study's secondary endpoints were procedure-related minor complication rate, sensitivity, specificity, and diagnostic accuracy for the characterization of malignancy. Tissue samples allowed histological diagnosis in 27/30 procedures (technical success rate 90.0%), as in three cases (10.0%) the sample was characterized as non-diagnostic: one case was suspicious for pancreatic cancer and two cases were cholangiocarcinoma. In one case, biopsy was successfully repeated. The diagnosis was cholangiocarcinoma in 16 cases (53.3%), colorectal metastasis in three cases (10%), pancreatic adenocarcinoma in three cases (10.0%), and inflammation in five cases (16.6%). There were two false-negative cases of inflammation proven to be cholangiocarcinoma, resulting in sensitivity of 91.67%, specificity of 100%, and accuracy of 92.59%. No major complications were noted. There were four cases of hemobilia (13%) which auto-resolved within 48 h. Percutaneous transluminal biopsy of biliary strictures during PTBD using the specific forceps system was proven safe and resulted in high technical success and diagnostic accuracy rates.

Hemobilia: Perspective and Role of the Advanced Endoscopist.

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon cause of gastrointestinal hemorrhage. Hemobilia has been documented since the 1600s, but due to its relative rarity, it has only been more critically examined in recent decades. Most cases of hemobilia are iatrogenic and caused by procedures involving the liver, pancreas, bile ducts, and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other major causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described, but this is present in only 25–30% of patients with hemobilia. Historically, the gold standard for diagnosis and treatment has been angiography and interventional radiologic intervention, respectively. However, the paradigm is shifting, at least in select cases, towards first-line reliance on noninvasive imaging (e.g., computed tomography) and therapeutic endoscopy, owing to advances in and the less invasive nature of both, while saving interventional radiological and/or surgical intervention for refractory or imminently life-threatening cases.

Acute Upper Gastrointestinal Bleeding: Think Outside the Ampulla

Bleeding from the hepatobiliary tract (hemobilia), is a rare cause of an acute upper GI bleed. It should be considered in any patient with a recent history of hepatic parenchymal or biliary intervention, angioembolization, blunt abdominal trauma or hepatic malignancy. We describe a case of hemobilia due to hepatocellular carcinoma (HCC) invading the gallbladder wall.Figure. 3: 1 cm oval-shaped, arterial-phase enhancing lesion in the lateral aspect of the right hepatic lobe (arrow) suspicious for residual HCC within close proximity to the gallbladder.Figure: EGD demonstrating blood oozing within the 2nd portion on the duodenum (A) and oozing from the Ampulla of Vater (B).A 52 year-old female with PMHx of Laennec's cirrhosis complicated by HCC status post transarterial chemoembolization (TACE) presented with black tarry stools, dizziness and abdominal pain. Physical exam was significant for right upper quadrant tenderness to palpation and melanotic stools. Labs were consistent with severe anemia, thrombocytopenia and liver profile derangement. An MRI performed the month prior to admission, demonstrated a 3.1 cm oval-shaped, arterial-phase enhancing lesion in the lateral aspect of the right hepatic lobe, suspicious for residual HCC (fig. A). She was aggressively transfused multiple blood products and placed on a proton pump inhibitor and octreotide drip. An emergent EGD was performed which identified blood oozing from the Ampulla of Vader; consistent with a diagnosis of hemobilia (fig. B). A CTA was negative for active extravasation. The presumed etiology was invasion of the residual HCC into the gallbladder wall given the close proximity identified on MRI. Given her history of TACE and severe liver dysfunction, she was not a candidate for embolization and she was medically managed. First recorded in 1654 by Francis Glisson, hemobilia is an exceedingly rare condition with an unknown exact incidence. Traumatic etiology accounts for 40 - 80 percent of all cases. In patients with HCC, invasion into the blood vessels (most commonly portal vein) is a frequent feature, however gallbladder and ductal invasion is widely unrecognized. One study involving 24 patients with HCC was performed to describe the features of intra-bile duct invasion. 21% developed hemobilia; one patient subsequently died from hemorrhagic shock. Approximately one-third of all patients will present with Quincke's triad: acute upper GI bleed (100%), biliary colic (70%) and jaundice (60%). Diagnosis is by visualizing blood from the Ampulla of Vader via EGD or ERCP. The best diagnostic and therapeutic intervention is angiography with embolization (success rate > 95%). Despite aggressive intervention, severe hemobilia has been shown to have a mortality as high as 25%.

Two cases of hemobilia: with rare cause

Two cases of hemobilia: with rare cause

Hemobilia a Rare Entity: Case Report and Literature Review

That is a condition hemobilia occurs infrequently in clinical practice, have different etiologies. It is defined by the presence of blood in the bile duct. Characterized by the classic triad of jaundice, right upper quadrant pain and upper gastrointestinal bleeding. For diagnosis we can use different complementary studies, imaging and endoscopic. Treatment is surgical Generally. A case of hemobilia in a chronic cholecystitis operated by patient developed obstructive jaundice WHO, with upper gastrointestinal bleeding and abdominal pain. It was as definitive treatment Performed ligation of the right hepatic artery with satisfactory evolution.