From the Guidelines
I strongly recommend angiography with selective arterial embolization for this patient. The clinical presentation suggests a hemobilia, which is bleeding from the biliary tract, likely as a complication of the recent liver biopsy. The patient has clear signs of significant bleeding (hypotension, tachycardia, dark red blood on rectal exam) with evidence of biliary obstruction (biliary ductal dilation on ultrasound) 1. The EGD found blood in the duodenum without identifying the source, which is consistent with bleeding from the ampulla of Vater. Angiography with selective arterial embolization is the preferred treatment for hemobilia as it can both diagnose and treat the bleeding vessel in one procedure. This approach is minimally invasive and has high success rates for controlling bleeding.
According to the latest guidelines, in patients with cirrhosis who are actively bleeding from a non-portal hypertensive cause, active bleeding should first be addressed by local measures and/or interventional radiology procedures 1. In this case, angiography with selective arterial embolization is the most appropriate option. ERCP with stent placement would be less effective for active bleeding, partial hepatectomy would be unnecessarily invasive, and octreotide is primarily used for portal hypertensive bleeding rather than arterial bleeding from trauma. The patient should be stabilized with continued volume resuscitation and blood products as needed before the procedure.
It's also important to note that the patient's coagulopathy should be managed according to the latest guidelines, which recommend against routine correction of fibrinogen deficiency or the use of tranexamic acid to decrease the rate of procedure-related clinically relevant bleeding 1. The patient's bleeding should be managed with a focus on stabilizing their hemodynamics and addressing the underlying cause of the bleeding.
In terms of prevention of complications, the patient should be monitored for bleeding complications and managed accordingly, with a focus on preventing bacterial infections, hepatic encephalopathy, and deterioration of renal function 1. Antibiotic prophylaxis should be considered, and the patient's renal function should be preserved by adequate replacement of fluids and electrolytes.
Overall, angiography with selective arterial embolization is the most appropriate treatment option for this patient, and should be performed as soon as possible after stabilizing the patient's hemodynamics.