Haemobilia

Extrahepatic obstructive jaundice is caused by stenos-ing processes. The region of Vater s papilla is particularly affected, for example by inflammations, stones, duodenal diverticula, carcinoma, parasites, cicatricial stenosis or adenomatosis. In this respect, special mention should also be made of carcinoma, cicatricial strictures and gallstones (s. figs. 8.14, 8.15 32.1, 32.15), compression of the common bile duct due to a cystic duct stone (= Mirizzi syndrome), haemobilia, and various parasites - such as Ascaris lumbricoides (s. fig. 25.8 ). All of these disorders can be found in the area of the extrahepatic bile ducts. (9, t9)... 

After perforation (60-80% of patients), an aneurysm becomes manifest in the form of abdominal pain, which can be very severe. (129) When an intrahepatic haema-toma reaches the bile ducts, haemobilia may result (about 40% of cases) (133), just as compression of the excretory bile ducts may lead to the development of jaundice (in some 50% of cases). (134,138) Heavy bleeding into the free abdominal cavity constitutes an acute abdomen with signs of circulatory shock. Bleeding into the intestinal tract or into the portal vein is less frequent. Lethality due to rupture is 30-50% the prognosis for massive bleeding with haemoperitoneum is even poorer. 

S.Moodley J, Singh B, Lalloo S, Pershad S, Robbs JV (2001) Non-operative management of haemobilia. Br J Surg 88 1073-1076... 

Haemorrhage into the biliary tract is called haemobilia. It was first described in 1654 [1], but the condition was not termed haemobilia until 1948 [1, 2). The majority of cases are due to trauma (50%), operative trauma accounting for 15% [2], though this incidence may have increased with the introduction of laparoscopic biliary surgery [3]. Pancreatitis is a rare cause of haemobilia. 

Fig. 7.1a,b. Coeliac angiography in a patient with life threatening haemobilia 24 h post cholecystectomy revealed a large hepatic pseudoaneurysm (a) treated successfully by proximal and distal coil embolization (b)... 

Haemobilia requires treatment as spontaneous resolution is exceedingly rare and the mortality from ruptured pseudoaneurysms is in excess of 90%. Technically endovascular management is relatively simple and involves the proximal and distal embolization, with tightly packed steel coils, of the hepatic... 

The results of embolization for haemobilia are reported as being 95%-100% effective [3] even on an intention to treat basis and it should be the treatment of first choice. 

The complications of embolization for pancreatitis associated visceral pseudoaneurysms are the same as for the treatment of haemobilia. In addition and as mentioned the repeated use of bovine or human thrombin can lead to anaphylaxis and though rare, autologous thrombin is recommended. 

Aneurysms and pseudoaneurysms causing haemobilia or associated with pancreatitis are potentially fatal. Imaging, particularly CECT, is vital to their diagnosis. Conservative therapy is a poor option and treatment, which was formally via open surgery, is now best carried out by angiography and percutaneous coil embolization in haemobilia and for Type la and b pancreatitis associated pseudoaneurysms. Percutaneous CT guided thrombin therapy is indicated for Type 2 aneurysms. 

Sandblom P (1948) Haemorrhage in to the biliary tract following trauma traumatic haemobilia . Surgery 24 571 -86... 

Nicholson A, Travis S, Ettles DF et al (1999) Hepatic artery angiography and embolization for haemobilia following laparoscopic cholecystectomy. CVIR 22 42-47... 

Rai R, Rose J, Manas D (2003) Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent. World J Gastroenterol 9 2377-2378... 

Savader SJ, Trerotola SO, Merine DS et al (1992) Haemobilia after transhepatic biliary drainage treatment with transcatheter emholotherapy. JVIR 3 345-352... 

Luhtnaim A, Buter A, Abela J-E. Haemobilia causing cholangitis in a patient on dual anti-platelet treatment suffering from acute acalculous cholecystitis. Int J Surg Case Rep 2013 4(4) 368-70. 

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