Hemobilia

Hemobilia is bleeding into the biliary tract, causing gastrointestinal bleeding through the ampulla of Vater.

• Causes: iatrogenic (percutaneous liver biopsy, percutaneous transhepatic cholangiography and drainage, ERCP, laparoscopic cholecystectomy) in over 60%, blunt or penetrating hepatic trauma, hepatic artery aneurysm or pseudoaneurysm, tumours (hepatocellular carcinoma, cholangiocarcinoma), cholecystitis, gallstones, parasitic infection, vascular malformations, liver abscess, anticoagulation.
• Rare, with mortality 5 to 10% in massive bleeds.
• Latency after trauma or procedure can be days to weeks (pseudoaneurysm).
• Complications: haemodynamic instability, biliary obstruction by clot, cholangitis, pancreatitis, cholecystitis.

Quincke triad (present in about 40%): biliary colic, jaundice and gastrointestinal bleeding.

• Melaena or haematemesis, occult bleeding.
• Right upper quadrant pain, fever.
• Recent procedure, trauma or known aneurysm.
• Hypotension and anaemia.

• Upper endoscopy with a side viewing duodenoscope: blood or clot extruding from the ampulla (pathognomonic), excludes upper gastrointestinal sources.
• CT angiography (multiphase): active extravasation, pseudoaneurysm, hepatic injury, clot in the bile duct or gallbladder.
• Selective hepatic angiography: identifies the bleeding artery, enables embolisation.
• Ultrasound, MRCP, ERCP (filling defects from clots).
• Laboratory: haemoglobin, coagulation profile, liver tests.

• Resuscitation: IV access, crystalloid, red cell transfusion (target haemoglobin 7 to 8 g/dL), correct coagulopathy, stop anticoagulants, tranexamic acid 1 g IV.
• Transcatheter arterial embolisation (coils, glue, particles, covered stent): first line, success 80 to 100%, with low liver ischaemia risk when the portal vein is patent.
• Endoscopic or percutaneous clearing of biliary clots: ERCP with sphincterotomy, balloon sweeps, nasobiliary lavage, biliary stent for obstruction.
• Antibiotics for cholangitis or cholecystitis (ceftriaxone 2 g daily with metronidazole).
• Surgery for failure of embolisation: hepatic artery ligation, resection of the bleeding segment, cholecystectomy if the gallbladder is the source.
• Treat the cause (tumour, aneurysm, abscess drainage).
• Follow up CT angiography at 1 to 3 months for pseudoaneurysm recurrence.