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
|
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
|
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 |
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 |
|
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
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.
- Zhou HB. Hemobilia and other complications caused by percutaneous ultrasound-guided liver biopsy. World J Gastroenterol. 2014;20(13):3712-3715. doi: 10.3748/wjg.v20.i13.3712.
- Qureshi MS, Iqbal M, Butt MQ, Nomani AZ Iatrogenic post biopsy hemobilia with pseudoaneurysm. J Coll Physicians Surg Pak. 2014;24(11):865-867. doi: 11.2014/JCPSP.865867.
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