A 55-year-old male who underwent percutaneous transhepatic cholangiography for obstructive jaundice develops hematemesis 24 hours later while hemodynamically stable; what is the most appropriate next step?

Management of Hematemesis Following PTC

Immediate Next Step: Upper GI Endoscopy

In a hemodynamically stable patient who develops hematemesis 24 hours after percutaneous transhepatic cholangiography, upper GI endoscopy (Option B) is the most appropriate next step to identify and potentially treat the bleeding source.

This clinical scenario represents a critical diagnostic challenge because hematemesis following PTC suggests either:

1. Hemobilia (bleeding from the biliary tree into the GI tract) - the most likely complication given the recent biliary instrumentation
2. Upper GI source unrelated to the procedure (peptic ulcer, gastritis, varices)

Rationale for Upper GI Endoscopy First

Why Endoscopy Takes Priority

• Direct visualization and therapeutic capability: Endoscopy allows immediate identification of the bleeding source AND simultaneous treatment if a non-vascular lesion is found (ulcer, Mallory-Weiss tear, gastritis) 1

• Hemobilia diagnosis: If blood is seen emanating from the ampulla of Vater during endoscopy, this confirms hemobilia and directs subsequent management toward angiography 2

• Hemodynamic stability permits diagnostic approach: The patient's stable vital signs allow for a systematic evaluation rather than emergent intervention 1

• Excludes common upper GI sources: Before attributing bleeding to a procedural complication, standard upper GI bleeding sources must be ruled out, which endoscopy accomplishes efficiently 1

Why Other Options Are Less Appropriate

CT Abdomen (Option A)

• CT may show hematoma, fluid collections, or vascular abnormalities but cannot definitively identify the source of hematemesis or provide therapeutic intervention 1
• CT is more appropriate for evaluating intra-abdominal complications (bile leak, hematoma) rather than upper GI bleeding 3
• Should be considered after endoscopy if hemobilia is confirmed or if endoscopy is non-diagnostic

Ultrasound (Option C)

• Ultrasound can identify bilomas and fluid collections but has limited ability to diagnose active bleeding sources 3, 4
• Cannot visualize the upper GI tract or ampulla to confirm hemobilia
• Useful for follow-up assessment but not as the initial diagnostic test for hematemesis 4

Angiography (Option D)

• While angiography is the definitive treatment for hemobilia once diagnosed, proceeding directly to angiography without endoscopic confirmation wastes resources if the bleeding source is non-vascular 2
• Angiography requires active bleeding rates of at least 0.3-1 mL/min for detection 1
• Should be performed urgently after endoscopy confirms hemobilia (blood from ampulla) 2

Subsequent Management Algorithm

If Endoscopy Reveals Hemobilia (Blood from Ampulla)

1. Proceed immediately to selective hepatic angiography within 1 hour of endoscopic diagnosis 1, 2

2. Angiographic findings may include 2:

   • Hepatic artery pseudoaneurysm (most common post-PTC)
   • Arteriovenous fistula
   • Active contrast extravasation
   • Hepatic artery-bile duct fistula

3. Perform selective transarterial embolization using gelfoam particles and/or coils to stop bleeding 2

   • Technical success rate: 90-95% 5
   • Immediate hemorrhage control expected 2

If Endoscopy Reveals Non-Biliary Source

• Treat according to standard upper GI bleeding protocols (PPI therapy, endoscopic hemostasis for ulcers, band ligation for varices) 1

If Endoscopy Is Non-Diagnostic

• Obtain CT angiography to evaluate for vascular injury, pseudoaneurysm, or intra-abdominal bleeding 3
• Consider repeat endoscopy or angiography if bleeding continues 1

Critical Pitfalls to Avoid

• Do not delay endoscopy in stable patients - it provides both diagnosis and potential therapy while ruling out common non-procedural causes 1

• Do not assume all post-PTC hematemesis is hemobilia - standard upper GI bleeding sources must be excluded first 1

• Do not perform angiography without endoscopic confirmation unless the patient becomes hemodynamically unstable, as this may lead to unnecessary intervention 1, 2

• If hemobilia is confirmed, do not delay angiography - selective hepatic artery embolization should be performed urgently (within 1 hour) for optimal outcomes 1, 2

• Monitor for rebleeding - approximately 15-45% of patients may experience recurrent bleeding depending on the underlying pathology, requiring repeat embolization 1, 2