Endovascular and Endoscopic Treatment of Hemobilia: A Report of Two Cases

Abstract

Hemobilia is a term used to describe bleeding caused by abnormal communication between blood vessels and bile ducts. Some vascular anomalies, such as aneurysms or arterio-biliary fistulas, facilitate the appearance of this type of biliary bleeding. Other causes have been described such as iatrogenic causes secondary to percutaneous procedures, infections, tumors, and trauma. We report two cases of hemobilia. The first one presented with acute biliary bleeding with secondary hypovolemic shock. Bleeding was controlled after percutaneous interventions with a selective embolization technique. The second case was a patient who presented to the emergency department after a fall from his height. During hospitalization, acute cholangitis was documented, associated with hemobilia. A wide papillotomy and biliary duct instrumentation were done with the extraction of a large blood clot. Angiography is the standard for diagnosis and embolization becomes the best tool for the detection and control of vascular abnormalities that can perpetuate bleeding.

Keywords: computed tomography (ct ); endovascular procedure; gastrointestinal bleeding; hemobilia; upper endoscopy.

Figure 1. (A and B) Fluoroscopy in retrograde endoscopic cholangiography: dilatated common bile duct with blood clot mold in its interior; (C and D) Adequate drainage with full opacification in control images

Figure 2. (A-E) Papillotomy and extraction of blood clot in biliary duct with posterior (F) metallic auto-expandable stent implantation with hemorrhage control

Figure 3. CTA (A) and 3D angiographic study (B) reconstruction of the abdomen showing the presence of a pseudoaneurysm is documented in a segmental branch of the right hepatic artery with a diameter greater than approximately 12 mm (arrows); a biliary stent previously placed in the common bile duct can also be seen

CTA: computed tomography angiography; 3D: three-dimensional

Figure 4. Digital subtraction angiography image showing selective injection through a microcatheter and identifying the presence of a pseudoaneurysm of a segmental branch of the right hepatic artery (arrow). Active contrast medium extravasation is not documented.

Figure 5. (A and B) Contrast tomography of the abdomen in coronal and axial views of the arterial phase with evidence of aneurysmal lesion (arrows) dependent on the right hepatic artery with signs of bleeding, (C) Fluoroscopy with angiographic evidence of an aneurysmal lesion of the right hepatic artery (arrow), and (D) subsequent successful embolization with coils (arrow)

Figure 6. (A and B) Papillotomy and extraction of blood clot in biliary duct and bleeding control