Hemobilia: Etiology, diagnosis, and treatment☆

Abstract

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon but important cause of gastrointestinal hemorrhage. Reports of hemobilia date back to the 1600s, but due to its relative rarity and challenges in diagnosis, only in recent decades has hemobilia been more critically studied. The majority of cases of hemobilia are iatrogenic and caused by invasive procedures involving the liver, pancreas, bile ducts and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other leading causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described (i.e. Quincke's triad), but this is present in only 25%-30% of patients with hemobilia. Therefore, prompt diagnosis depends critically on having a high index of suspicion, which may be based on a patient's clinical presentation and having recently undergone (peri-) biliary instrumentation or other predisposing factors. The treatment of hemobilia depends on its severity and suspected source and ranges from supportive care to advanced endoscopic, interventional radiologic, or surgical intervention. Here we provide a clinical overview and update regarding the etiology, diagnosis, and treatment of hemobilia geared for specialists and subspecialists alike.

Keywords: Diagnosis; Etiology; Hemobilia; Hepatopancreatobiliary interventions; Imaging; Upper gastrointestinal hemorrhage.

Fig. 1. Evolving etiologies of hemobilia over time.

A transition can be seen from traumatogenic to iatrogenic cases of hemobilia over time.^–

Fig. 2. Proposed algorithm for the diagnosis and management of hemobilia.

(i) Vascular complications include hepatic artery aneurysms, pseudoaneurysms, and cholangio-venous or arterio-ductal fistulae. (ii) If endoscopic therapy is not successful in achieving hemostasis, IR techniques should be attempted. The converse may also apply, depending on the clinical scenario. (iii) Surgical exploration is indicated for biliary obstruction (or hemostasis) when endoscopic and IR techniques fail or are not applicable. Abbreviations: CT, computed tomography; IR, interventional radiology; ERCP, endoscopic retrograde cholangiopancreatography.

Fig. 3. Hemobilia emanating from a recently placed fully-covered self-expanding metallic stent.

Esophagogastrojejunoscopy demonstrated numerous red-maroon clots occluding the metallic stent, requiring extensive intraductal irrigation and clot extraction as well as concomitant correction of coagulopathy.

Fig. 4. Common endoscopic accessories relevant to management of hemobilia.

(A) extraction balloon; (B) heater probe; (C) bipolar probe; (D) dilation balloon; (E) retrieval basket; (F) injection needle.

Fig. 5. Cholangiographic images of hemobilia.

(A) Intraductal lucencies (arrows) suggestive of occlusive clot formation are seen fluoroscopically. A self-expanding metallic stent is also noted in the biliary tree. (B) A flower basket is used to extract clot from the biliary tree. Resultant air cholangiograms are seen, with arrows denoting pneumobilia.