What is the diagnosis and management of Hemobilia?

Hemobilia: Diagnosis and Management

Definition and Clinical Presentation

Hemobilia is bleeding into the biliary tract that most commonly presents with jaundice (89%), right upper quadrant abdominal pain (78%), and gastrointestinal bleeding (melena in 14%), though the classic Quincke's triad (jaundice, pain, and upper GI bleeding) occurs in only 25-30% of cases. 1, 2

Key Clinical Features to Assess:

• Recent procedural history: Liver biopsy, percutaneous transhepatic cholangiography (PTC), ERCP, hepatobiliary surgery, or trauma 3, 1, 4
• Hemodynamic status: Vital signs, transfusion requirements, ongoing resuscitative needs 3
• Associated symptoms: Fever, drop in hemoglobin, abnormal inflammatory response 3, 5

Diagnostic Algorithm

Initial Evaluation

When hemobilia is suspected, duodenoscopy should be performed first to identify bleeding from the ampulla of Vater, which confirms the diagnosis in most cases. 4, 2

Confirmatory Imaging

Selective angiography is the gold standard for diagnosis, allowing both confirmation and localization of the bleeding source, and should be performed in hemodynamically stable patients. 6, 4, 7

• CT scan with IV contrast is recommended when jaundice develops with concerning features (abdominal pain, fever, hemoglobin drop) and can identify pseudoaneurysms 3, 5
• Ultrasound is useful for detecting bile leak/biloma and can identify fluid collections, particularly in grade IV-V liver injuries 3, 5
• ERCP demonstrates characteristic cholangiographic findings: amorphous filling defects (41%), tubular filling defects (16%), or cast-like filling defects (16%) 2

Etiology-Based Risk Stratification

Most Common Causes:

• Iatrogenic injury (post-procedural): Liver biopsy, PTC, biliary interventions 3, 1, 4
• Trauma: Blunt or penetrating hepatic injury 3, 1, 7
• Hepatobiliary malignancies: Hepatocellular carcinoma (38%), bile duct/gallbladder cancers (32%) 2
• Hepatic artery pseudoaneurysm: Often post-traumatic, high rupture risk 3, 5

Management Strategy

Hemodynamically Stable Patients

In hemodynamically stable, non-septic patients with hemobilia, angiographic embolization is the treatment of choice and should be performed as the initial intervention. 3, 4

• Selective arterial embolization successfully controls bleeding in the majority of cases and is safer than surgery 3, 4
• Endoscopic biliary drainage (nasobiliary catheter or stent placement) should be performed to relieve biliary obstruction caused by blood clots 3, 2
• ERCP with stenting is particularly effective for intrahepatic bilio-venous fistulas 3

Hemodynamically Unstable Patients

Patients with ongoing resuscitative needs require angioembolization as an "extension of resuscitation" to reduce transfusion requirements and avoid surgery. 3

• Angioembolization can be safely repeated if initial attempt fails 3
• Serial hemoglobin monitoring and clinical reassessment are mandatory for detecting delayed bleeding 3, 5

Surgical Intervention

Surgery should be reserved for patients in whom angiographic embolization fails, or when hemobilia is associated with extrahepatic sources (gallbladder bleeding) or underlying conditions requiring definitive treatment (tumors, parasitic disease). 6, 4

• Major liver resection may be required for tumor-related hemobilia with definitive control of both bleeding and underlying pathology 4
• Operative arterial ligation is necessary when nonoperative attempts fail 4

Critical Pitfalls to Avoid

• Do not delay angiography in suspected hemobilia: Early selective angiography allows both diagnosis and therapeutic embolization in a single procedure 6, 4
• Do not miss hepatic artery pseudoaneurysm: Even in asymptomatic post-traumatic patients, pseudoaneurysms have high rupture risk and require early angioembolization 3, 5
• Do not assume stability means resolution: Patients require serial hemoglobin monitoring and clinical reassessment for delayed bleeding or complications 3, 5
• Do not perform PTBD as first-line: Percutaneous biliary drainage can cause significant complications including biliary peritonitis, hemobilia, pneumothorax, and liver abscesses 3
• Avoid routine follow-up CT in all cases: CT is only indicated when abnormal inflammatory response, abdominal pain, fever, jaundice, or hemoglobin drop develops 3, 5

Post-Treatment Monitoring

• Biliary complications occur in 30% of cases after hepatic trauma and may require ERCP with stenting, percutaneous drainage, or surgical intervention 3
• Re-bleeding occurs in 69% of cases but can usually be managed non-operatively with repeat embolization 3
• Infected bilomas require antibiotics and percutaneous or surgical drainage 3, 5