Review Article Open Access
Hemobilia Post Liver Biopsy: Mechanism, Presentation, Complications and Management
Norman Oneil Machado*
Department of Surgery, Sultan Qaboos University hospital, Muscat, OMAN
*Corresponding author: Norman Oneil Machado, Department of Surgery, Sultan Qaboos University hospital, Muscat, OMAN, PO Box: 28, Postal code: 123, Tel: 0-96-8 99-432723; E-mail: @
Received: September 09, 2015; Accepted: November 16, 2015; Published: November 28, 2015
Citation: Machado NO (2015) Hemobilia Post Liver Biopsy: Mechanism, Presentation, Complications and Management. Gastroenterol Pancreatol Liver Disord 2(4): 1-14. http://dx.doi.org/10.15226/2374-815X/2/3/00142
Abstract Top
Background: Liver biopsy is the gold standard for diagnosing various liver pathology. However, it may be associated with serious complications such as hemobilia, information of which is scarce in the literature.

Objective: This article intends to review various aspects of hemobilia including the mechanism, presentation, diagnosis and management.

Method: Literature review. A systematic review of the literature was performed by searching the PubMed and Medline databases, for all relevant articles in English on hemobilia, published from 1963 to June 2015.

Discussion: The search resulted in retrieval of 56 studies, involving 78 patients with hemobilia. The method of biopsy included percutaneous(51.8%), ultrasound guided percutaneous biopsy(29.6%), transjugular(11.1%), laparoscopic biopsy(3.7%). The predominant symptom of presentation was pain and GI bleed(42.2%), Quincke's triad(39.4%). The mean day of presentation was 5 days. The investigations carried out included angiogram(68%),LFT(47.9%), ultrasound abdomen(45.2%), ERCP(24.6%), endoscopy(16.4%). The vascular anomaly contributing to hemobilia were arteriobiliary fistula(32.6%), arterioportal fistula(36.9%), pseudoaneurysm(21.7%) and arteriovenous biliary fistula(trifistula) (4.3%). Transarterial embolization was carried out in 61.2% of patients with 80% success in arresting bleeding. ERCP with clot extraction was carried out in 20.9%. Surgical intervention included cholecystectomy (23%), CBD exploration and clot extraction (9.23%) and hepatic artery ligation (right or left branch)(9.23%). The complications observed were pancreatitis (41.8%), hemocholecystitis(21.8%), cholangitis(10.9%). Death was seen in 3.6% of patients.

Conclusion: Hemobilia is a rare complication post liver biopsy . Angiogram is both diagnostic and therapeutic. Surgical interventions is limited to those who fail to respond to arterial embolization or develop complications in the gall bladder or CBD.

Keywords: Hemobilia; Liver biopsy; Transarterial; Embolization
Introduction
Hemobilia refers to bleeding into the biliary system. Several reports indicate its occurrence post liver biopsy [1-63]. Hemobilia was first described by Glisson in 1654, in a postmortem diagnosis of a young adult, stabbed by a sword in the liver [46]. Sandblom in 1948 used the term hemobilia to describe hemorrhage into the biliary tree, secondary to trauma [49].It was first reported as a complication of liver biopsy in 1967 [44]. In one of the largest multicenter study, reporting on the complications of liver biopsy, hemobilia was noted in 4 of 68,276 patients (0.006%) [50]. In another report, the incidence of hemobilia, post percutaneous liver biopsy was reported to be 0.023% among 12,750 patients, accounting to 11.5% of all major complications [39]. However, several recent reports indicate the incidence of hemobilia post liver biopsy to be higher at just below 1% [20] and include 0.70% (1/142) [47] and (0.1%) [5, 7]. In this article the literature is reviewed and various factors that influence its cause and its management has been discussed.
Methods
Literature review. A systematic review of the literature was performed on hemobilia, by searching the PubMed and Medline databases for all relevant articles in English, published from 1963 to June 2015. The articles were retrieved using the MeSH(Medical Subject Headings) terms "hemobilia" and "liver biopsy". The data was extracted and studied for demographic details, method of liver biopsy, primary liver disorder warranting a biopsy, clinical presentation, the time of presentation, complications and management including radiological, endoscopic and surgical.
Results
The search resulted in retrieval of 56 studies involving 78 patients and majority (88%) of these studies were case reports; seven of them were case series with 2 or more cases. Unfortunately, some of the studies lacked data regarding various parameters studied and hence the statistics had to be derived from data available (DA). Table 1 and Table 2. There were 21 male and 27 female patients (DA=48 patients) with an average age of 43.9 years (range 1.7-75 years). The biopsy methods included percutaneous biopsy (51.8%), ultrasound guided percutaneous biopsy (29.6%), transjugular biopsy (11.1%), laparoscopic biopsy (3.7%) and laparotomy and biopsy (1.85%). The predominant symptom of presentation was pain and GI bleed (42.2%), Quincke's triad (39.4%), pain and jaundice (5.6%), GI
Table 1: Demographic Details, Presentation, Complications.

 

No

Of pts

Age- in yrs

 

Sex

Liver Biopsy

Technique

Presentation

Pain

Jaundice

GI bleed

Day- of presentation Post

procedure

Complications

Cholecystitis

Cholangitis

Pancreatitis

Zhou HB1

2014

1

57

F

USbps

P

GiBl-mel

7

Cholecystitis

Cholangitis

Pancreatitis

Stress gastric ulcers

Qureshi2 2014

1

29

F

Pbps

QT

5

NA

Zaleska-Dorobisz3

2014

1

10

M

USbps

P

GiBl-Mel/hem

7

Nil

Howlett DC7

-2013

(UK audit)

2/ 3455bpsy

NA

NA

P

GI-Bl Mel  =2

NA

NA

Plerhopies TA4

2013

1

69

F

TJbps

QT

<1

Cholecystits, gall bladder rupture,

Intra-abdominal fluid collection

Marynissen T5

2012

6/12 HB

NA

 NA

QT-6

 

6

NA

Gandhi V6

2011

1/22(HB)

NA

USbps

NA

6

NA

Kawakubo K8

2011

1

67

M

EUS-bps

P

J

4

Nil

Egritas O9

2010

1

7

F

USbps

P

Gibl- Hem& Mel

2

Cholecystitis

pancreatitis

Koshy CG11

2010

 1

36

F

Tjbps

Hypotension-4hr after procedure

<1

4hr

Intra-peritoneal bleeding from subcapsular venous pseudoaneurysm

Hendriks M10

2009

1

42

F

USbps

P

Gibld-hem

4

Pancreatitis

CBD obstruction

Peña LR12

2009

 1

56

M

Pbps

P

J

7

Pancreatitis

Reaccumulation of clot after initial extraction. repeat ERCP 3days and stenting

Wood B13

2009

 1

11

M

USbps

P

GiBl- Mel

14

Pancreatitis

Li F14

2009

 1

51

M

USbps

P

GiBl- Mel.

1hr

Pancreatitis

Prata F15

2008

2

45&37

F&M

2-USbps

QT-2

5 &4

cholangitis

Rogart JN16

2008

1

58

F

Tjbps

P

Gi-bl- Mel

2

Pancreatitis

Gurakuqi GC17

2008

1

60

M

TJbps

(advanced liver disease)

P

Gi-Bl-Hem

1

Died- multiorgan failure

Bergmann OM18

2007

1

55

F

Tjbps

J

Confusion

2

Bilhemia with deteriorating LFT

Acute pancreatitis

ARDS

Dallal RM19

2007

 1

34

F

Laparoscbps- during bypass surgery for obesity

P

1

Nil

Edden Y20

2006

1

15


M

Pbpsy

P

12

Cholecystitis. Persistent fullness of GB with blood- 14 days

Albuquerque W21

2005

1

21

F

 NA

QT

1 hr

Pancreatitis,

Cholecystitis .

 

Nowak A23

2005

1

55

F

Pbps

P

4

Pancreatitis

Lin CL24

2005

1

68

F

USpbs

P

2

Recurrence of bleeding after discharge following ERCP- embolization after 2 days

Kruse-Jarres22

2005

1

39

M

Tjbps

P

LFT-abnormal

4

nil

Hodgson RS25

2004

1

63

F

USbps

NA

4

Pancreatitis

Sharma R26

2004

1

55

M

NA

QT

3

Nil

Hashimoto M48

2004

3/ (8 cases of HB)

NA

USbps

P

Gibl-Mel

- 3 Cases

3

Liver infarction post embolisation

Rossi47

2002

1/ 142 (usbps)

53

F

USbps

P

Gi-Bl- Mel

6

NA

Machicao VI51

2002

1

49

M

Pbps

P

Gi-bleed

10

Pancreatitis

Sood  A.52

2002

1

55

M

Pbps

QT

NA

Pancreatitis

Asselah T27

2001

 1

43

F

Pbps

P

Gibl-Mel

4

Pancreatitis

Coelho JC28

2001

1

47

M

Pbps

P

Gi-bl-Mel

2

Cholecystitis

Gomez-Valero29

2001

1

53

F

Pbps

P

Gibl-Mel

4

Pancreatitis

Gama-Odrigues J30

2001

2

NA

Pbps

P

Gibl-2 Cases

5

NA

Moehler M32

2000

1

43

F

Mini-laparcBps

P

4

NA

Eurvilaichit C33

1999

1

35

F

Pbps

P

Gi-bl- mel

3

NA

Jornod P34

1999

1

75

F

Pbps

P

J

8

Pancreatitis

Lee SL35

1999

1

30

F

Pbps

P

Gi-bl-Hem&Mel

2

Necrotic GB-cystic duct blocked with clot

Kim  HJ36

1999

1

NA

NA

NA

NA

Cholecystitis / Pancreatitis

Kwauk ST37

1998

1

35

F

Pbps

Gibl-Mel

J-2 weeks later after lap cholecystectomy

10

nil

Acalculouscholecystitis

Richardson SC38

1998

1

49

M

USbps

P

GIbl-Mel

9

Pancreatitis

Dousset B39

1997

11

NA

Pbps

QT- 7

4=NA

Median-3

(1-25)

Pancreatitis-32%- (4 pt)

Cholangitis-37%  (4 pt)

Cacho G45

1996

1

NA

Pbps

P

GI-bld- mel

3

Cholecystitis

Grieco A53

1996

1

65

F

Pbps

QT

18hr

Nil

Van Os EC54

1996

1

64

M

Pbps

P

Gi- bl- hematochezia

 

24hr

Pancreatitis

Jabbour N55

1995

3

26,64,1.7

M=2, F=1

Pbps=1

Laprbps=1

Usbps=1

1 pt-Asymptomatic- detected during routine angiogram post transplant

2ndpt-J+ Gibld

3rdpt= abnormal LFT=hepatic angiogram  detected

NA

Multiorgan failure-1

Liver infarction-1

De Ribot X56

1995

1

55

F

Pbps

P

GIbl-Mel

1

Pancreatitis

Figueras J57

1994

1

7

F

Pbps

P

Gi-bl-Mel

24hr

Died of massive bleeding despite TAE and before surgical intervention

Merhav58

1993

1

41

M

Pbps

P

Gi-bl-Mel

1

NA

Manzarbietia59

1993

1

51

M

USbps

P

Gi-bl-Mel

3

Pancreatitis

Lichtenstein DR

199240

1

39

M

Pbps

P

Gi-bl- mel-48 hrs later

4

NA

Okazaki M

199160

1/10 HB

NA

Pbps

P

Gi-bl-Mel-Hem

2

NA

Attiyeh FF41

1976

1

16

M

Pbps

 QT

 

3

NA

Ball TJ42

1975

1

 

Pbps

QT

 

2

NA

Levinson JD43

1972

 1

40

M

Pbps

QT

2

NA

Cox EF44

1967

1

27

F

Pbps

QT

NA

NA

 

78

M=21

F=27

Age- Avg-43.9

Range-1.7 to 75

 

 

 

DA=48 cases

Pbps=28

Usbps-16

Tjbps- 6

Lapcbps=2

Laprbps=1

EUSbps=1

 

 

 

 

 

DA=54 cases

QT= 25

P+Gibl=30

P+J=4

RAPT=2

Gibl=2

J=1

Hypotension=1

Confusion=1

 

 

 

DA =71 cases

 

Median -4 days

 

 

 

 

 

 

 

 

 

 

DA=72 cases

Cholecystitis-12 (21.81%)

Pancreatitis-23 (41.81%)

Cholangitis- 6 (10.9%)

Liver Infarction-2 (3.6%)

Mulitiorgan failure-2 (3.6%)

 

Bilhemia-1 (1.81%)

Death-2 (3.6%)

 

DA=55 cases

HB= haemobilia, USbps= ultrasound guided biopsy, Pbps=percutaneous biopsy, Tjbps= transjugular biopsy, EUS-bps= Endoscopic ultrasound guided biopsy, Lapcbps= laparoscopic biopsy, Laprbps= laparotomy and biopsy, DA= data available, P=pain, J= Jaundice, Gibl=GI bleed, Gibl-Mel= Gi bleed presenting as melena, GIbl-hem= Gi bleed presenting as hematemesis, QT=Quincke's triad, NA= not available, RAPT= routine angiogram post transplant
Table 2: Investigations, Management and Complications.

Series

Year               

Investigations

Nature of fistula

 

Management

 

(radiological/ endoscopic)

Surgical

Procedure

Discharge Day-

Post

procedure

Hepatic disorder/co-morbidities

Zhou HB1

2014

LFT

US

MRCP

Endoscope

DSA

AVBF

TAE-

Rt hepatic artery

Nil

12 days

Abnormal liver function

Qureshi2

2014

LFT

Angiogram

Endoscope

 ABF

TAE

ERCP- ClExt

Nil

NA

Nil

Zaleska-Dorobisz3

2014

LFT

US

Endoscopy

Angiogram

ABF

APF

TAE- rt hepatic artery-GianturooWallaoh coil

Nil

4

Chronic hepatitis B

Howlett DC7

-2013

(UK audit)

NA

NA-2

NA=2

NA=2

NA

NA

Plerhopies TA4

2013

LFT

CT

ERCP

 

NA

ERCP-ClExt/stenting

Perc-chol

Nil

3

Portal hypertension/deteriorating LFT/Hemosiderosis/ ESRD

Marynissen T5

2012

LFT

CT-2

US-4

Angiogram-6

NA-6

TAE-6

NA

NA

NA

Gandhi V6

2011

LFT

CT

Angiogram

NA

NA

NA

NA

NA

Kawakubo K8

2011

LFT

CT

Endoscope

NA

Nasobiliary drainage

Nil

 8

Nil

Egritas O9

2010

LFT

CT

Endoscope

NA

Supportive measures- blood products/iv fluids

Nil

10

Mitochondrial disease, familial intrahepatic cholestasis

Koshy CG11

2010

Endoscope

Hepatic Angiogram

Hepatic venogram

APF

PsdA

Supportive measures

TAE

Hepatic vein embolization-platinum coils

Nil

Few days

Cryptogenic liver cirrhosis, portal hypertension, moderate ascites

Hendricks MP10

2009

US

ERCP-elongated opacities-blood clots

NA

ERCP –sphincterotomy+ stent

Nil

NA

Psoriasis

Liver biopsy to rule out methotrexate induced hepatitis

Peña LR12

2009

LFT

MRCP

ERCP

NA

ERCP-spinterotomy+ ClExt-balloon +stenting

Nil

 NA

Chronic hepatitis C

Wood B13

2009

LFT

Endoscopy

CT

Angiogram

ABF

PsdA

NA

NA

NA

NASH

Li F14

2009

LFT

CT

MRCP

NA

Supportive measures only

 Nil

2

Alcoholic cirrhosis

Post liver / kidney transplant

Prata F15

2008

LFT-2

US-1

CT-1

ERCP-2

NA-2

ERCP-sphincterotomy +ClExt -2

Nil

NA

Cirrhosis

Rogart JN16

2008

LFT

CT

Endoscope

Angiogram

ABF

TAE

Nil

NA

Hepatitis C  infection

Gurakuqi GC17

2008

LFT

Endoscopy

Angiogram

ABF

TAE

Nil

died

Alcoholic cirrhosis

Severe coagulopathy

Bergmann OM18

2007

LFT

US

ERCP

Angiogram

AVBF  (trifistula)

TAE

ERCP-ClExt-stenting

Nil

5

ESRD

Malignant melanoma

Dallal RM19

2007

LFT

US

HIDA scan

ERCP

NA

NA

Lap chol

CBD exploration

NA

Hypertension, gastro-oesophageal reflux, polycystic ovarian syndrome

Edden Y20

2006

US

On table cholangiogram

NA

Supportive measures

Lap chol and on table cholangiogram

2

Persistent elevated liver enzymes/  cryptogenic cirrhosis

Albuquerque W21

2005

US-free fluid in peritoneal cavity. GB- echogenic material

ERCP+MRCP- edematous pancreatitis/dilated GB,CBD clots

Angiogram- no further bleeding seen

NA

ERCP- ClExt -balloon

Lap chol- 5 days after ERCP for recurrent abd pain

NA

Biopsy- preop for renal transplant protocol.

Hepatitis C

 

Kruse-Jarres22

2005

US

CT

NA

Conservatively with factor V111 replacement only

Nil

4

HIV

Hepatitis C

Congenital hemophilia

Nowak A23

2005

Endoscope

ERCP

NA

ERCP ClExt=dormia basket-nasobiliary tube-thrombin infusion

Nil

2

Diabetic

Chronic elevation of ALAT- non-alcoholic steatohepatitis

Lin CL24

2005

US- Gb-polypoidal mass

ERCP-blood in ampulla- clot in CBD

APBF

ERCP-sphincterotomy-CLExt,

TAE- with gel foam-segment VII

Nil

7

Chronic  C hepatitis

 

Hodgson RS25

2004

US-free fluid around GB

Angiogram-pseudoaneurysm/AP biliary fistula

APBF

PsdA

TAE- Titanium microcoils

Nil

4

Crohn's disease

Sharma R26

2004

LFT- abnormal

US- dilated GB, mild IHD dilatation

CT-distended GB, IHD dilatation, blood clot in CBD

Angiography-filling defect in Rt lobe

MRI/MRCP- for follow up

NA

TAE

Nil

NA

Hepatitis B

Hashimoto M48

2004

US

CT

Angiogram

PsdA-2

ABF-1

TAE

Nil

NA

 

Rossi47

2002

US

ERCP-Blood clot in CBD

Angiogram

ABF

TAE

Nil

7

Hepatitis C

Machicao VI51

2002

LFT

CT

Angiogram

APF

TAE

Nil

NA

Hepatitis C

Sood  A52.

2002

LFT

CT

ERCP

NA

ERCP-sphincterotomy +ClExt

Nil

NA

Hepatitis C

 

Asselah T27

2001

LFT

US

MRCP- acute pancreatitis/CBD clot

NA

NA

NA

NA

 

Coelho JC28

2001

US-thick walled GB-blood clot intraluminal

NA

NA

Lap cholecystectomy

 

 

Gomez-Valero29

2001

US

Angiogram

APF

TAE

Nil

3

 

Gama-Odrigues J30

2001

US

Angiogram

Laparoscopy

ABF=2

Conservative measures=2

Lap cholecystectomy and ligation of hepatic artery- 2 cases

NA

NA

Moehler M32

2000

US

Angiogram

APF

TAE

Nil

3

Nil

Eurvilaichit C33

1999

US

Angiogram

ABF

TAE-gelfoam

Nil

3

Nil

Jornod P34

1999

LFT

US

ERCP

NA

ERCP-sphincterotomy- ClExt

Nil

3

Primary biliary cirrhosis

Lee SL35

1999

LFT-abnormal

Angiogram- no source of bleed seen

RBC tagged scan-post cholecystectomy(abnormal LFT/persistent pain)-NAD

ERCP- clot in CBD

NAD

ERCP- postop on 5th day –Sphincterotomy-ClExt

Open cholecystectomy-on 3rd day- necrotic GB

 

NA

Hepatitis C

Went home and returned after 72 hrs

 

Kim  HJ36

1999

NA

NA

NA

NA

NA

NA

Kwauk ST37

1998

CT-hematoma rt lobe of liver

ERCP-normal CBD/pancreatic duct

LFT- abnormal-2 weeks later

Angiogram-24 days after initial presentation and lap chole

 

PsdA

TAE—coil

 

Percutaneous drainage of gall bladder bed collection

Nil

11

Biliary cirrhosis

Richardson SC38

1998

ERCP

APF

NA

NA

NA

Hepatitis C

Dousset B39

1997

LFT=11

US=11

Angiogram-11

APF=4

PsdA=2

ABF==3

NAD=1

Vascular flask=1

TAE- successful= 7

 

Failed =2

technical difficulty

 

Complicated=1

(ischemiccholecystitis

Cholecystectomy=7

Rt hepatic artery ligation=2

NA

NA

Cacho G45

1996

US

Endoscopy

Angiogram

APF

TAE

Cholecystectomy

NA

nil

Grieco A53

1996

US

Angiogram-AV fistula- 3rd liver segment

ERCP-clot

AVF

TAE- gelfoampledgets

ERCP+Sphincterotomy+ClExt

Nil

NA

Polyneuropathy/ endocrinopathy/ monoclonal gammapathy

Van Os EC54

1996

Angiogram

Endoscopy

PsdA

TAE

Nil

NA

Drug related hepatitis

Jabbour N55

1995

(3 cases)

Doppler-2

Angiogram-3

Radionucleide scanning-1

Endoscopy-1

APF-3

Conservative-2

TAE-1

CBD exploration, and 2nd liver transplant for infarction-1 case

NA

Non A/B hepatitis-1

Chronic active hepatititis-1

Cat's eye syndrome-1

deRibot X56

1995

ERCP

NA

NA

 

NA

NA

Chronic elevated liver enzyme

Figueras J57

1994

Angiogram

ABF

TAE

Nil

Died

Post liver transplant

Merhav58

1993

US

Angiogram

PsdA

Directpercutaneous emoblisation-ultrasound guided.(DPE)

 

TAE-technically was not possible- tortuous allograft hepatic artery

Nil

NA

Post liver transplant

Manzarbietia59

1993

CT

MRCP

NA

NA

NA

NA

Post liver transplant

Lichtenstein DR

199240

US

Angiogram

ABF

TAE- gelfoam and Gianturco coil

Nil

3

Nil

Okazaki M60

1991

US

Angiogram

ABF

TAE-gelfoam

NA

NA

Nil

Attiyeh FF41

1976

LFT

US

NA

Supportive measures only

Cholecystectomy/CBD exploration/left hepatic artery ligation

 

Hodgkins disease

Ball TJ42

1975

LFT

ERCP

Angiogram

NAD

NA

NA

NA

NA

Levinson JD43

1972

LFT

Angiogram-linear collection of contrast close to biopsy

NAD

ND

T tube decompression of CBD

Left hepatic artery branch ligation

NA

Micronodular cirrhosis

Granulomatous liver disease, Sarcoidosis

Cox EF44

1967

NA

NA

NA

NA

NA

NA

 

Angiogram=50(68%)

LFT=35 (47.9%)

US=33 (45.2%)

ERCP=18 (24.6%)

Endoscope=12 (16.4%)

MRCP=6 (8.21%)

Radionucleide scan=3 (4.1%)

 

 

 

 

DA=73

ABF=15

(32.6%)

APF=16

(16.9%)

PsdA=10

(21.7%)

AVBF=2

(4.34%)

NAD=4

(8.69%)

 

 

DA=46

TAE=38 (61.2%)

 

ERCP+ClExt=13 (20.9%)

Supportive measures only=11 (17.7%)

DPE=1(1.6%)

Percchol=1(1.6%)

NBD=1(1.6%)

 

 

DA=62

 

 

NPP=30 (46.1%)

Chcyst=15 (23.07%)

CBDE=4 (6.15%)

HAL=6

(9.23%)

 

 

 

 

DA=65

Median=6 days

 

LFT=liver function test; US= ultrasound; MRCP= magnetic resonance cholangiography; DSA= digital subtraction; CT=computerized tomogram; IHD=intra hepatic duct; DPE=direct percutaneous embolization; NBD= nasobiliary drainage; HAL=hepatic artery ligation=6; Chcyst= cholecystectomy; CBDE= CBD exploration; NPP= no procedures performed; AVF= arteriovenous fistula; ABF=arteriobiliary fistula; APF= arterioportal vein fistula; PsdA= pseudoaneurysm; NA= not available; NAD= no abnormality detected; AVBF= arteriovenous biliary fistula; TAE= transarterial embolization; ClExt= clot extraction; PercChol= percutaneous cholecystectomy; ESRD= end stage renal disease; NASH= non alcoholic steatotic hepatitis
bleed alone (2.8%), and those detected on routine angiogram post liver transplant and liver biopsy (2.8%) and one case each of confusion (1.96%), hypotension and jaundice alone. The mean day of presentation was 5 days. The investigations that facilitated in diagnosis included angiogram (68%), LFT (47.9%), ultrasound (US) abdomen (45.2%), ERCP (24.6%), endoscopy (16.4%), MRCP (8.2%) and radio nucleide scan (4.1%). Angiogram detected arteriobiliary fistula in (32.6%), arterioportal fistula (36.9%), pseudoaneurysm (21.7%), arteriovenous biliary fistula-Trifistula (4.3%) and no abnormality (8.69%), among the 46 patients were data was available. Transarterial embolization was carried out in 61.2% and was successful in 80% of these cases in arresting the bleeding. ERCP with clot extraction was required in 20.9% of patients where CBD clot persisted. In 17.7% of patients no radiological or endoscopic measures were carried out and were managed with supportive therapy only. There was one patient each who underwent percutaneous cholecystostomy, nasobiliary drainage of the biliary tract and ultrasound guided direct percutaneous injection of the vascular fistula, due to technical difficulty in catheterisation and embolization of hepatic artery because of its tortuosity. No additional surgical procedures were carried out in 46.1%; however among the remaining patients, 23% underwent cholecystectomy, 6.15% underwent CBD exploration and clot removal and 9.23% underwent hepatic artery ligation. The complications noted were pancreatitis (41.8%), cholecystitis (21.8%), cholangitis (10.9%), liver infarction in patients with liver transplant (3.6%), multiorgan failure (3.6%), bilhemia (1.8%) among the 55 patients were data was available. Death was noted in 2 patients(3.6%). The median stay of patients was 6 days. However in many of the patients with complications, the data of discharge was not available and the median day of stay of 6 days noted, is likely to represent those without complications.
Mechanism
The term hemobilia relates to bleeding into the biliary system. Majority of the bleeding are post liver biopsy, a reflection of the recentincrease in this invasive procedure, to establish diagnosis of liver pathology [62].They could also be secondary to gallstones, vascular malformations, parasitic infestation, inflammation, tumours, post cholecystectomy [6, 63], acute cholecystitis [64] and trauma [6]. Most of the bleeding is into the intra-hepatic biliary system [1-6, 9-22]. However, bleeding into extrahepatic bile ducts and gall bladder is also reported [8]. The vessels that could be involved include cystic artery, anomalous hepatic artery, portal vein andhepatic artery or its intrahepatic branches [1, 6].Due to the close proximity of the intrahepatic bile duct, hepatic artery and portal vein, a puncture needle during liver biopsy,could easily lead to injuryof all these structures to form arteriovenous bile duct fistula, arterial bile duct fistula and venous bile duct fistula [1]. Bleeding from venous bile duct fistula often stops spontaneously, because of low venous pressure [1]. The bleeding of venous origin could however lead to significant bleeding, if they bleed freely into peritoneal cavity through a subcapsular located bleeding site [11]. An arteriobiliary fistula on the other hand is likely to be symptomatic because of bleeding from a high pressure vascular system into low pressure biliary tract. Hemobilia could also be due to pseudoaneurysm, which was seen in 21% in this review. The pseuodaneurysm formation may be delayed after a biopsy and are usually a consequence hematoma, progressive compression, and chronic inflammation, all leading to low-grade damage within the liver parenchyma [18,20,55]. This could then predispose to aneurysmal changes in the adjoining hepatic arterial branch, forming a pseudoaneurysm [55]. The risk of vascularbiliary fistula is believed to be increased, when biopsies are carried out in the presence biliary duct obstruction and infection, as the hepatic arterial blood flow increases in such condition [1]. Moreover, hyperplasia and distension of the arterial peribiliary vascular plexus and the feeding hepatic artery branch in periportal area enhances this risk [1]. Fistula involving the hepatic artery, hepatic vein and biliary tree could cause an intrahepatic trifistula leading to bilhemia and Hemobilia [18]. Bilhemia (bile in vascular system) could causepersistent deterioration of the liver function and confusion post procedure, which can be controlled after treating the fistula [18].The direction of blood flow and development of bilhemia and hemobilia is to a large extent influenced by the intravascular biliary duct pressure gradients. The pressures in healthy subjects are as follows. (1) hepatic artery 100 mmhg, (2) bile duct 10 to 15 mmhg, (3) portal vein 10 mmHg, and (4) hepatic vein 0 to 5 mmHg [18]. The pressure gradient between intrahepatic hollow structures can be affected by pathophysiological changes in various disease states, including cirrhosis and common bile duct obstruction. A supraphysiological biliary-venous pressure gradient(>10mm Hg) is needed to cause clinically significant bilhemia, which may happen in the presence of bile duct obstruction [18]. When pressure is≤10mm Hg, fistulas are likely to close spontaneously. When hepatic artery is involved, the highpressure system is more prone to persistence of fistula.
Risk of hemobilia in patients with coagulation disorder
Like any other invasive procedure, liver biopsy in patients with coagulation disorders including congenital bleeding disorders is at a risk of bleeding complications [22, 62]. These procedures however can be carried out safely in these patients, if they are under adequate cover of coagulation factors, in the periprocedure period [22]. There are differing opinions as to what constitutes an abnormal coagulation index that would determine a contraindication for liver biopsy. Most centers consider an international normalised ratio (INR)> 1.5 and platelet count of <50,000/mm as strong contraindication [61].
The pathophysiology of Blood clot in Bile duct
The blood does not normally clot within the bile duct because of fibrinolytic activity of bile [65]. However, sometimes the clot if formed, fails to lyse. Sandblom et al reported that when the hemorrhage is severe and rapid, the blood mixes with bile and forms mushy clot [65]. When hemobilia is minor and slow, the mixture does not result, but leads to blood flowing and settling at the bottom, where it forms a solid pure clot that forms cast of the lumen [65]. These pure clots remain stable, whereas mixed clots dissolve rapidly. Hence the fate of clots is related to the bile flow, with the dissolution of clot being rapid when flowing blood is exposed to bile [65, 66]. The difference in surface tension between bile and blood could be another factor that could lead to stasis and clot formation [65].
Presentation
The classical presentation of hemobilia constitutes the Quincke's triad [2, 9] and includes right upper quadrant pain, jaundice and acute gastrointestinal hemorrhage. This is reported in some series to be seen in 50% [38] to 63% of patients [39]; however it constituted 40% of the presentation in this review. The most frequent clinical finding is upper gastrointestinal bleeding (90%); right upper quadrant pain (70%) and jaundice (60%) [9]. The mean interval is reported to be 5 to 6 days following the liver biopsy [2,5, 6, 15, 30, 47]. Hemobilia may present immediately [11, 21, 57] or may be delayed up to a week or as late as 25days [39].The clinical manifestation of hemobilia is determined by the amount and speed of hemorrhage into the biliary tract [1, 6]. Profuse hemobilia often causes severe symptoms with colicky pain and gastrointestinal hemorrhage [65,66]. However, often the bleeding is occult and lacks clinical significance as the blood inconspicuously flows into the intestine [65,66]. Blood clots in the gall bladder can mimic biliary colic or induce hemocholecystitis [20, 21, 45], while the blood clot in CBD may present with obstructive jaundice or complications of pancreatitis [23,25,51,52] and cholangitis, similar to patients with choledocholothiasis [1, 12, 24].
Liver biopsy technique and its influence in causing hemobilia
Liver biopsy is carried out by percutaneous transhepatic approach or by transjugular approach [11, 62]. Transjugualr approach is preferred in patients with severe coagulopathy, ascites, massive obesity or suspected vascular tumours [4, 11,62]. Patients who require simultaneous vascular procedures (such as Venogram or Transjugular Intrahepatic Portosystematicshunt (TIPS) placement or when percutaneous biopsy has failed would be better served by a transjugular approach [62]. The procedure would involve, inserting a catheter into the hepatic vein through the right internal jugular vein, under fluoroscopy guidance. The liver biopsy forceps is then introduced to blindly obtain tissue. The drawback however is that the samples are smaller than those obtained by percutaneous approach [4,62]. It warrants several passes in order to obtain an adequate pathologic specimen with a reported success rate of 97% [4]. The complication rate is around 2.% and comprises mild (abdominal pain, neck hematoma transient Horner's syndrome) or more severe complications (hemobilia, gall bladder puncture, cardiac arrhythmias, pneumothorax, perforation of liver capsule, sampling of adjacent organs) [4]. Although ultra-sound guided biopsies are relatively safer, complications including hemobilia are reported [9, 13, 25, 48]. Complications of percutaneous liver biopsy are fortunately uncommon. Majority (96%) of them appear in the first 24 hours and the remaining 4% usually have their clinical presentation within 10 days [50]. The presence of cirrhosis and neoplasm however increase the risk of complications [20]. In addition to the underlying disease, the risk of complications would also depend upon the coagulative status, the type and the diameter of biopsy needle used and the number of needle passes, despite being ultrasound guided [6, 9, 62]. US guidance however would reduce the risk of undesired puncture of surrounding organs.Major complications are higher in patients with focal lesion (1.3%) compared to 0.3% in those without a focal lesion [7]. Hemobilia has also been reported following endoscopic ultrasound biopsy of hilar carcinoma through transdudoenal bulb approach [8] and also in those where the biopsy has been carried out laparoscopically [19,32].
Complications of hemobilia
Several complications could occur as a consequence of blood in the biliary system [1].The blood clot could cause obstructive jaundice and may lead to acutecholecystitis [1,4,20,21], cholangitis [1,15] and acute pancreatitis [1, 9, 10, 12-14, 23], intra-abdominal fluid collection [4], persistent distension of gall bladder with gall bladder rupture [4], and acute gastric stress ulcers [1]. Blood clot could raise the intra biliary duct and pancreatic duct pressure leading to acute pancreatitis [1].The clot may disappear in few days time [9, 10] particularly in those who had interventions to drain the biliary system or it may persist longer [20]. In those where the clot in gall bladder persists, have been reported to form gallstones, few months later [35]. Percutaneous cholecystostomy could reduce the GB and biliary tract pressure [4]. Reducing the biliary tract pressure can prevent pancreatitis [1]. Arteriovenous fistula bleeding in the liver often results into an intra-hepatic hematoma and occasionally portal hypertension [1,67]. Lim et al have reported that percutaneous liver biopsy could result in arteriovenous fistula in 38% (8/21) of cases after biopsy [67]. However vascular biliary injury noted in this review included arteriobiliary fistula (32.6%), arterioportal fistula (36.9%), pseudoaneurysm (21.7%) and arterio venous biliary (trifistula) (4.3%). The predominant complications noted in this review included pancreatitis (41.8%), hemocholecystitis (21.8%) and cholangitis (10.9%).
Investigations
The bleeding through the papilla into the duodenum can be established by endoscopy in 33% [39] to 60% of the cases[6,24,68]. Ultrasound doppler could help in diagnosis of a pseudoaneurysm and would appear as a well circumscribed anechoic lesion with a turbulent flow [1, 6, 24, 55]. Contrast enhanced CT scans can demonstrate hematoma, anatomical variations, pseudoaneurysm and cavitating lesions [26, 67]. The appearance on US and CT varies depending on the rapidity and severity of bleeding. US and CT scan may note the hydropic gall bladder and surrounding edema compatible with cholecystitis [9, 22]. Intracholecystic bleeding typically appears as echogenic , non-acoustic polypoidal mass [22, 24]. The echotexture becomesa reticular stranding sludge, as clot lyses [24]. The border of the clot becomes concave and gall bladder appears to have polypoidal mass [24]. MRCP may reveal associated pancreatitis, cholecystolithiasis, cholangiectasis and abnormal signal indicating muddy stone or hematocele in CBD [1]. MRCP shows a negative magnetic signal in the biliary duct and gall bladder, corresponding to the clot in it [21]. If ERCP is performed, it could demonstrate the blood emerging from the papilla figure 1 and the intraluminal blood clot could be documented as filling defect figure 2 [10, 24]. Digital subtraction angiogram (DSA) could detect the site of bleeding and fistula, when the rate of blood loss is> 0.5 ml/min [1]. A strong suspicion of hemobilia warrants an urgent angiography for its diagnostic and therapeutic value. This is in the form of an initial celiac axis angiography, combined with superior mesenteric arteriography, to determine a possible abnormal origin of an anomalous /accessory right hepatic artery from SMA in 20% of the patients [6]. A selective right and left hepatic angiogram are likely to localize the bleeding better, particularly in the presence of pseudoaneurysm [6]. Unfortunately angiogram may appear normal in some patients in the absence of active bleeding or when there is no demonstrable lesion [6, 39]. In the event bleeding continues or recurs, a repeat angiogram is worthwhile and advisable [6].Angiography findings in hemobilia could include arterio-portal fistula, arteriobiliary fistula and pseudoaneurysm [24]. Arterio-portal fistula is reported to occur in 5% of the cases and may remain asymptomatic [24].
Treatment
The main principle in management of hemobilia is resuscitation, control the source of bleeding and maintain the biliary patency [9, 39]. Resuscitation with transfusion is carried out to obtain hemodynamic stabilitywhen hemorrhage is severe and rapid [1, 6, 9, 13, 12]. Any existing coagulopathies are simultaneously dealt with [22]. Nearly 50% of the patients will stop bleeding with the supportive measure of blood products [9, 22, 24, 37, 42, 55]. The remaining patients would require therapeutic interventions, which would involve Transarterial Hepatic Artery Branch Embolization (TAE). TAE is most prudent in patients with pseudoaneurysm, arteriobiliary fistulas, or arterioportal fistula [1,69]. Superselective embolization is safer and more effective treatment for active bleeding. It is carried out using a microcatheter and is desirable as it minimizes spasm and avoids occlusion of the noninvolved arterial branches, particularly in liver transplant patients [69]. Hence, selective embolization as close as possible to the pseudoaneurysm or fistula is opted for,to limit the likelihood of both recurrence and liver necrosis [48,69]. The risk of inadvertent ischemic cholecystitis, hepatic artery main branches embolization, is also avoided [39].

In transplant patients, liver graft dysfunction and biliary ischemia are potential risks.

Embolisation could be carried out using gelatin sponge, autoallergy-sludged blood, spring orb, microcoils, polyvinyl alcohol particles and cyanoacrylate glue [1,6,24]. Coils induce thrombosis and hence for obvious reason may be ineffective in patients with gross coagulopathy [6]. Smaller pseudoaneurysm where coil placement may be difficult, may be effectively treated with cyanoacrylate glue as it conforms to the shape of the pseudoaneurysm,forms a cast instantly and is cheaper than microcolis [6]. Hypophysin is also reported to be commonly used [1].The success rate of arresting bleeding with TAE intervention is reported to range from 63% [6], 94% (16 out of 17) [6] to 100% [5]. In one of older series involving 11 cases hemobilia,transarterial embolization was successful in 63%, with 18% having technical failure and I case (9%) with ischemic cholecystitis [39]. Recent reports however indicate higher success rate [5, 6]. Failure to arrest bleeding could be due to technical reasons or extensive collaterals [39].In the presence of extensive collaterals,embolization, distal and proximal to the pseudoaneurysm will be required [6]. Alternatively the pseudoaneurysm is occluded with microcoil or glue in addition to proximal occlusion with coils [6].Technical failure could also be due to a tortuous vessel, as in an allograft artery, post transplant [58] or due to intimal injury and spasm of the vessel, during manipulation of the catheter [60]. In very rare cases, it could be due to bleeding into peritoneal cavity of venous origin [11]. In one of the reports, persistent bleeding post TAE was localized to bleeding into the peritoneum from a feeding hepatic vein branch [11]. The bleeding, which was occurring through a subcaspular site, was effectively controlled by transjugular hepatic venogram and embolization [11]. In a post transplant patient where there
Figure 1: Blood Clot Seen at the Ampulla (arrow) in a Patient with Hemobilia.
Figure 2: ERCP Revealing Multiple Clots in CBD as Filling Defects (arrows).
is difficulty in achieving TAE because of technical difficulty in cannulating a tortuous allograft artery, the bleeding has been successfully dealt with by direct embolization of the aneurysm, under ultrasound guidance [58]. This review noted that TAE was carried out in 63% of the patients with 80% success in arresting the bleeding.

Having controlled the bleeding, the attention is then directed to a potential biliary tract obstruction, due to intraluminal clots. If the intraluminal clot does not dissolve and persist beyond 24 to 48 hours leading to progressive deterioration of liver function tests and dilatation of the bile duct (reflected by radiological imaging), then clot extraction and bile duct drainage would be required [4]. Biliary obstruction by clot may require ERCP sphincterotomy and balloon extraction of clots [2, 4, 15, 23]. Recurrent clot formation after an initial successful clot extraction may warrant a repeat of the procedure [12]. Endoscopic nasobiliary drainage has also been used to decompress the biliary tract [8, 23]. In addition, thrombolytic agents have been infused through a nasobiliary catheter to dissolve the biliary clots [70]. Routine placement of biliary stent in the presence of hemobilia is controversial. While some would stent the ampulla to prevent reaccumulation of clot [12], there are others who are concerned of stent forming a nidus which may act as matrix for thrombus attachment and worsening of obstruction [35, 37]. In liver transplant patients who develop hemobilia post liver biopsy, endoscopic approach may not be feasible because of anatomical distortion post bile duct reconstruction. In them, the clots can be dealt by transhepatic approach, to break up the clots progressively and increase its contact surface to flowing bile [71]. In patients with persistent distended gall bladder, a percutaneous transhepatic cholecystostomy could relieve the symptoms, particularly in patients with significant co-morbidities [4].

The role of surgery over the years has declined, after the advent of successful radiological intervention, in arresting bleeding in most of the cases[6, 24, 37].However, surgical intervention will be required when the above measures fail [6, 24].Emergency surgery to control major hemobilia is challenging and hazardous and should be avoided, as the results are poor [6]. Surgical intervention however is unavoidable in the absence of angiographic facility, failure of TAE or in the presence of hepatic sepsis [6]. In the absence of angiographic facility, every attempt should be made to transfer these patients to a center with these facilities. The principle of surgery is to control the bleeding vessels [40, 42], extraction of biliary clots with lavage and biliary tract drainage [39,41]. In the presence of liver necrosis or liver sepsis, a limited liver resection may be warranted. Post ERCP and sphincterotomy, reports suggest the disappearance of clot in GB, within a couple of weeks [24]. However in some cases, despite decompression of the biliary system by ERCP sphincterotomy, the clot in the gall bladder may persist, requiring cholecystectomy. This may deal with symptom related, both to acute cholecystitis or possible dyskinesia [21, 35, 37].The timing of the cholecystectomy could either be immediate [20, 35] or delayed [37], based on the existing symptoms and is carried out preferably laparoscopically.

In addition to performing cholecystectomy, laparoscopic approach has been used to simultaneously carry out ligation of hepatic artery, in patients with persistent bleeding [30].

The reported mortality post iatrogenic hemobilia is around 10 to 12% and is mostly related to those who required surgical intervention [39]. In the recent years the success of angiographic embolization has significantly reduced the need for surgical intervention and hence the mortality. This review noted the mortality in 3.6% of the cases.
Conclusions
Hemobilia is a rare complication of liver biopsy, but is being noted with increasing frequency due its predominant role in establishing diagnosis in various liver pathology. The presentation could be variable but GI bleeding in the presence of jaundice and or pain post liver biopsy, should alert the clinician. Endoscopy and angiogram play a significant role, both as diagnostic and therapeutic tool. Off late, transarterial embolization arrests bleeding in majority of these patients. Role of surgical intervention is limited to those with complications of hemocholecystitis, failure of TAE in arresting bleeding and persisting clot induced obstructive jaundice, despite endoscopic intervention
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