Hemobilia

Abstract

Hemobilia is a rare source of upper gastrointestinal bleeding, though the incidence is increasing along with the rise in minimally invasive biliary interventions. Prompt diagnosis and treatment rests on having appropriate clinical suspicion which should be based on the patient's presenting signs and symptoms, as well as history including recent instrumentation. Endoscopy should be reserved for cases of upper gastrointestinal bleeding with low suspicion for hemobilia. Interventional radiology may be the first-line diagnostic and therapeutic option for patients with a high suspicion of hemobilia. While embolization is the mainstay of therapy, other options include thrombin injection, stent placement, and/or placement of a percutaneous biliary drain. Surgery should be reserved for failed treatment by interventional radiology.

Keywords: embolization; hemobilia; imaging; interventional radiology.

Fig. 1

Flowchart of diagnostic evaluation of hemobilia.

Fig. 2

Hepatic artery pseudoaneurysm. (a) Percutaneous transhepatic cholangiogram with relatively central puncture site (arrow). (b and c) Axial and coronal CT images show the internal–external biliary drain crossing a segmental hepatic artery (dashed circle). A small pseudoaneurysm can be seen on the axial series (arrow). (d) Selective segmental hepatic arteriogram clearly shows a 3- to 4-mm pseudoaneurysm (white arrow) where the biliary catheter (black arrow) crosses the hepatic artery. (e) Microcoil embolization (arrow) of segmental hepatic artery pseudoaneurysm from distal to proximal.

Fig. 3

(a and b) Large 5-m pseudoaneurysm (arrow) resulting as a complication of laparoscopic cholecystectomy performed for choledocholithiasis. (c) After unsuccessful attempt at placement of covered stent in hepatic artery due to angulation of celiac artery and proper hepatic artery, coil embolization of the proper hepatic artery with extension into the common hepatic artery was performed.

Fig. 4

(a) Coronal imaging in portal venous phase suggests possible portal-biliary communication. (b) Contrast injection through sheath opacified the biliary system (arrow) and remained static with no drainage into the small bowel. (c, d) Retraction of sheath uncovered portal-biliary fistula and allowed portal flow to briskly “wash out” contrast in the biliary tree as noted by the lower contrast density in the more delayed images. (e) Viabahn covered stent (arrow) placed within segmental biliary duct to exclude portal-biliary fistula. A new 8.5F biliary drain placed to facilitate clearance of clot within the biliary system.