Haemobilia

Bleeding into the biliary tree from an abnormal communication between a blood vessel and a bile duct

Aetiology

• Iatrogenic trauma to liver and biliary tree (most common - 50%)
  • Percutaneous liver biopsy 1%
  • PTC 2-10%
  • Liver resections
  • Cholecystectomy
• Trauma
• Gallbladder inflammation
• Primary vascular diseases
  • Aneurysms
  • Angiodysplasia
  • Haemangiomas
• Malignancy
• Parasitic infections
• Hepatic abscesses
• Cholangitis

Presentation

• Classic triad (present in 22%)
  • Upper abdominal pain
  • Upper GI bleeding
  • Jaundice
• Major haemobilia
  • Melaena
  • Haematemesis
  • Biliary colic
  • Jaundice
• Generally benign and self-limiting
• Arterial haemobilia can be dramatic

Workup

• Gastroscopy
  • Only diagnostic in 10%
• US/CT
  • Intra-hepatic tumour or haematoma
  • Active bleeding
• Arterial angiography is frequently diagnostic (90% according to Sabiston)
• Cholangiography - blood clots in biliary tree that might look like stones

Management

• Stop the bleeding and relieve biliary obstruction
• Major haemobilia - angiography and embolisation
• Haemobilia after PTC - either removal of catheter or upsizing, but may still require embolisation
• Surgery indicated when embolisation has failed
  • Ligation of bleeding vessels
  • Excision of aneurysms
  • Non-selective ligation of a main hepatic artery
  • Hepatic resection in severe cases