Harvey's Garden

Hemobilia

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3 min read

A condition of bleeding from the biliary tree.

Epidemiology & Risk Factors

  • Iatrogenic trauma is the most common cause (>50% of cases): c
    • Percutaneous liver biopsy.
    • Percutaneous transhepatic cholangiography (PTC) or percutaneous biliary drainage (PTBD).
    • ERCP or laparoscopic cholecystectomy.
    • TIPS procedure.
  • Non-iatrogenic trauma (blunt or penetrating abdominal trauma).
  • Vascular abnormalities:
    • Hepatic artery pseudoaneurysm or aneurysm rupture.
    • Arterio-biliary fistulae.
  • Hepatobiliary malignancies (cholangiocarcinoma, hepatocellular carcinoma [HCC], liver metastases).
  • Gallstones (eroding into hepatic vessels) and parasitic infections (e.g., Ascaris lumbricoides).

Clinical Features

  • Quincke’s Triad (present in ~30–40% of cases):
    1. RUQ pain (biliary colic due to clot obstruction/distension).
    2. Obstructive jaundice (from clots blocking bile ducts).
    3. Upper GI bleeding (melena, hematemesis, or hematochezia).
  • History of recent hepatobiliary instrumentation (days to weeks prior).
  • Signs of hemorrhagic shock/anemia (tachycardia, hypotension, pallor) in severe hemorrhage.

Diagnosis

  • Initial Lab Testing:
    • Complete Blood Count (CBC): ↓ Hb/Hct (anemia).
    • LFTs: ↑ Direct Bilirubin, ↑ ALP & GGT (obstructive pattern). Mild-to-moderate ↑ AST/ALT.
    • Coagulation panel (PT/INR, PTT) to assess for underlying coagulopathy.
  • Initial Imaging:
    • RUQ Ultrasound: Often the first test. Shows echogenic material (blood clots) in the gallbladder or bile ducts, ductal dilation, or rules out other biliary pathology.
    • CT Abdomen / CT Angiography (CTA): Identifies vascular etiologies (e.g., pseudoaneurysms, fistulae), parenchymal hematoma, or active contrast extravasation.
  • Confirmatory / Gold Standard:
    • Angiography: Most sensitive and specific for identifying vascular lesions (e.g., hepatic artery pseudoaneurysm, active arterial bleeding). Provides simultaneous therapeutic intervention.
    • EGD / ERCP: Directly visualizes blood/clots egressing from the ampulla of Vater (confirms active hemobilia).

Differential Diagnostics

  • Upper GI Bleeding (Non-biliary):
    • Peptic Ulcer Disease (PUD) / Mallory-Weiss Tear / Varices: Diff by lack of Quincke’s triad (no jaundice/biliary colic), and EGD shows direct luminal bleeding (e.g., gastric ulcer) rather than blood from the ampulla.
  • Choledocholithiasis:
    • Diff by absence of hematemesis/melena/anemia. RUQ US shows a gallstone in the CBD rather than mobile echogenic clots.
  • Acute Cholangitis:
    • Diff by Charcot’s Triad (fever, RUQ pain, jaundice) without overt GI bleeding, and leukocytosis is typically more prominent. (Note: Hemobilia complicated by clot obstruction can trigger secondary cholangitis).
  • Aortoenteric Fistula:
    • Diff by history of AAA repair or aortic graft, presenting with “herald bleed” followed by catastrophic GI hemorrhage without biliary symptoms.

Management

  • 1st Line (Emergency & Stabilization):
    • Hemodynamic Resuscitation: Large-bore IV access, IV crystalloids, packed red blood cells (PRBCs) as needed.
    • Correct Coagulopathy: Discontinue anticoagulants, administer Vitamin K, Fresh Frozen Plasma (FFP), or platelets.
    • Conservative Management: Indicated for minor/self-limiting hemobilia with close observation and biliary drainage if needed.
  • 2nd Line (Definitive Management for Persistent/Major Bleeding):
    • Transcatheter Arterial Embolization (TAE): Gold standard/first-line intervention for major or ongoing arterial hemobilia. Achieves hemostasis in up to 95% of cases.
    • ERCP / Endoscopic Biliary Drainage: Performed to relieve biliary obstruction, extract clots, and place stents to maintain bile duct patency.
  • Refractory (Surgical Intervention):
    • Indicated if TAE fails, is unavailable, or if bleeding is from a large hepatic artery aneurysm.
    • Includes surgical ligation of the bleeding vessel, cholecystectomy (if bleeding is from gallbladder/hemophilic cholecystitis), or segmental hepatic resection.

Complications

  • Obstructive Jaundice: Clots plug the common bile duct (CBD).
  • Acute Cholangitis: Biliary stasis from clot obstruction leads to bacterial superinfection.
  • Acute Pancreatitis: Blood clots obstructing the pancreatic duct (ampulla of Vater blockage).
  • Hemorrhagic Shock: Catastrophic blood loss from major arterial laceration.
  • Hemocholecystitis: Blood accumulating in the gallbladder, mimicking acute cholecystitis, with a risk of gallbladder necrosis/perforation.

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