Transcatheter arterial embolization in the management of hemobilia

Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology

For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.

Case report: Recurrent hemobilia due to hepatic artery pseudoaneurysm mimicking gastrointestinal tract bleeding

Hemobilia, a rare form of upper gastrointestinal bleeding (UGIB), is a potentially fatal complication that usually occurs after iatrogenic hepatobiliary trauma. However, hemobilia is clinically challenging to diagnose and often gets too late to diagnose. We herein report a case of recurrent hemobilia due to hepatic artery pseudoaneurysm (HAP) that was initially misdiagnosed as gastrointestinal tract bleeding. However, the patient was treated successfully with percutaneous coil occlusion of the pseudoaneurysm. This case illustrates that hemobilia can present as a mimic of gastrointestinal tract bleeding, but this is often difficult to diagnose at first glance and often misleads clinicians, especially emergency physicians, into making an incorrect diagnosis. Familiarity with the clinical features of hemobilia can help raise clinical suspicion and facilitate the early diagnosis and treatment of hemobilia.

A case of Mirizzi syndrome accompanied by a pseudoaneurysm that ruptured into the gallbladder: successfully treated by embolization of aneurysm and sequential surgery

Background

Although visceral aneurysms are relatively rare, it can be life-threatening in case it ruptures. We report a case of Mirizzi syndrome accompanied by a pseudoaneurysm that ruptured into the gallbladder.

Case presentation

The patient was a 73-year-old woman with persistent gastrointestinal bleeding and progressive jaundice. Examination revealed a pseudoaneurysm in the gallbladder artery or hepatic artery branch, and biliary hemorrhage due to gallbladder perforation was suspected. Urgent abdominal angiography revealed a pseudoaneurysm measuring 50 × 32 mm that had ruptured directly from the right hepatic artery or the cystic artery into the gallbladder. The pseudoaneurysm was successfully coiled and the bleeding was stopped. The presence of ongoing obstruction due to Mirizzi syndrome resulted in an emergency cholecystectomy being performed on the same day. On removing the impacted gallstone from the neck of the gallbladder, we found an obstruction between the lateral wall of the common bile duct and the gallbladder, this condition was diagnosed as Mirizzi syndrome with a biliobiliary fistula. After removing the impacted gallstone, a T-tube was inserted into the common bile duct. Bile leakage was observed postoperatively, but it improved with drainage. The patient fully recovered.

Conclusions

We present our experience with a case of Mirizzi syndrome accompanied by a ruptured pseudoaneurysm successfully treated with coil embolization followed by cholecystectomy. In this case, the pseudoaneurysm may have been caused by inflammation due to cholecystitis or compression of the arterial wall by a gallstone. To the best of our knowledge, Mirizzi syndrome associated with pseudoaneurysm rupture is rare. Our study suggested that cholecystectomy preceded by transcatheter arterial embolization is an effective strategy to control bleeding in patients with hemobilia due to aneurysm.

Severe Blunt Liver Injury Complicated by Delayed Massive Hemobilia in a Toddler: A Case Report and Literature Review

Introduction

Unintentional injuries remain a leading cause of disability among children. Although most of the pediatric patients suffering blunt liver injury can be successfully treated with non-operative therapy, the diagnosis and management of delayed life-threatening hemobilia following severe blunt liver injury, especially in the pediatric population, remain a challenge for clinicians.

Case Presentation

A previously healthy 2-year-old girl suffered a severe blunt liver injury related to an electric bike, which was inadvertently activated by herself. She initially received non-operative therapy and was in a stable condition in the first 2 weeks. On the 16th and 22nd postinjury days, the patient presented with life-threatening massive hemobilia, which was confirmed via repeat emergent gastroscopy and hepatic arterial angiography. An emergency selective transarterial embolization of the involved branch of the left hepatic artery was successfully performed. The patient recovered uneventfully, and long-term follow-up was needed owing to a mild dilatation of the left intrahepatic bile duct.

Discussion

Incidental injury in children should be considered as a major public health issue and preventive measures should be taken to reduce its occurrence. Delayed massive hemobilia after severe blunt liver trauma is rare, and its accurate and timely diagnosis via emergency hepatic arterial angiography and selective angioembolization may allow prompt and optimal management to achieve good outcomes in the pediatric population.

Hepatic Arterioportal Fistula in Patients with Cirrhosis with Endovascular Management—A Series of 4 Cases with Review of Literature

Hepatic arterioportal fistula (APF) in the setting of cirrhosis may aggravate the preexisting portal hypertension and its complications. Cirrhotic patients undergo various percutaneous invasive procedures and are at risk of developing an APF. These should be diagnosed early and should be treated accordingly at the earliest when indicated. Presently embolization is the treatment of choice with coil embolization as the most commonly used method. We describe four cases from our institute with a history of liver parenchymal disease and were found to have acquired APF on imaging. These were successfully managed with transarterial embolization with resolution or improvement in their clinical symptoms on follow-up. The present case series and review emphasize the importance of APF in the setting of liver parenchymal disease and the role of early diagnosis and therapeutic intravascular interventions.

Endoscopic-catheter-directed infusion of diluted (-)-noradrenaline for atypical hemobilia caused by liver abscess: A case report

BACKGROUND

Hemobilia occurs when there is a fistula between hepatic blood vessels and biliary radicles, and represents only a minority of upper gastrointestinal hemorrhages. Causes of hemobilia are varied, but liver abscess rarely causes hemobilia and only a few cases have been reported. Here, we present a case of atypical hemobilia caused by liver abscess that was successfully managed by endoscopic hepatobiliary intervention through endoscopic retrograde cholangiopancreatography (ERCP).

CASE SUMMARY

A 54-year-old man presented to our emergency department with a history of right upper quadrant abdominal colic and repeated fever for 6 d. Abdominal sonography and enhanced computed tomography revealed that there was an abscess in the right anterior lobe of the liver. During hospitalization, the patient developed upper gastrointestinal bleeding. Upper gastrointestinal endoscopy revealed a duodenal ulcer bleeding that was treated with three metal clamps. However, the hemodynamics was still unstable. Hence, upper gastrointestinal endoscopy was performed again and fresh blood was seen flowing from the ampulla of Vater. Selective angiography did not show any abnormality. An endoscopic nasobiliary drainage (ENBD) tube was inserted into the right anterior bile duct through ERCP, and subsequently cold saline containing (-)-noradrenaline was infused into the bile duct lumen through the ENBD tube with no episode of further bleeding.

CONCLUSION

Hemobilia should be considered in the development of liver abscess, and endoscopy is essential for diagnosis and management of some cases.

Recurrent right hepatic artery pseudoaneurysm after robotic-assisted cholecystectomy in a patient with Mirizzi syndrome: a case report

Background

Iatrogenic hepatic artery pseudoaneurysm is a rare complication following laparoscopic cholecystectomy. Trans-arterial embolization (TAE) is an effective way to control bleeding after a ruptured aneurysm. But uncommonly, rebleeding may occur which will require a second embolization or even laparotomy.

Case presentation

We report a case of a 45-year-old woman who underwent robotic-assisted cholecystectomy after the diagnosis of type II Mirizzi syndrome. During the operation, the anterior branch of the right hepatic artery was damaged and Hem-o-lok clips were applied to control the bleeding. The postoperative course was smooth, and the patient was discharged 6 days after the procedure. However, one week after hospital discharge, she presented to the emergency department with right upper abdominal tenderness, melena, and jaundice. After examination, the computed tomography angiography (CTA) revealed a 3 cm pseudoaneurysm at the distal stump of the right hepatic artery anterior branch. TAE with gelfoam material was performed. Three days later, the patient had an acute onset of abdominal pain. A recurrent pseudoaneurysm was found at the same location. She underwent TAE again but this time with a steel coil. No further complication was noted, and she was discharged one week later.

Conclusions

Even with the assistance of modern technologies such as the robotic surgery system, one should still take extra caution while handling the vessels. Also, embolization of the pseudoaneurysm with steel coils may be suitable for preventing recurrence.

Transcatheter arterial embolization for massive hemobilia with N-butyl cyanoacrylate (NBCA) Glubran 2

BACKGROUND

Massive hemobilia is a life-threatening condition and therapeutic challenge. Few studies have demonstrated the use of N-butyl cyanoacrylate (NBCA) for massive hemobilia.

PURPOSE

To investigate the efficacy and safety of transcatheter arterial embolization (TAE) using NBCA Glubran 2 for massive hemobilia.

MATERIAL AND METHODS

Between January 2012 and December 2019, the data of 26 patients (mean age 63.4 ± 12.6 years) with massive hemobilia were retrospectively evaluated for TAE using NBCA. The patients' baseline characteristics, severities of hemobilia, and imaging findings were collected. Emergent TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil. Technical success, clinical success, procedure-related complications, and follow-up outcomes were assessed.

RESULTS

Pre-procedure arteriography demonstrated injuries to the right hepatic artery (n = 24) and cystic artery (n = 2). Initial coil embolization distal to the lesions was required in 5 (19.2%) patients to control high blood flow and prevent end-organ damage. After a mean treatment time of 11.2 ± 5.3 min, technical success was achieved in 100% of the patients without non-target embolization and catheter adhesion. Clinical success was achieved in 25 (96.2%) patients. Major complications were noted in 1 (3.8%) patient with gallbladder necrosis. During a median follow-up time of 16.5 months (range 3-24 months), two patients died due to carcinomas, whereas none of the patients experienced recurrent hemobilia, embolic material migration, or post-embolization complications.

CONCLUSION

NBCA embolization for massive hemobilia is associated with rapid and effective hemostasis, as well as few major complications. This treatment modality may be a promising alternative to coil embolization.

Clinical features of hemobilia: Report of six cases and a literature review

BACKGROUND

Hemobilia is a rare cause of upper gastrointestinal bleeding. Diagnosis and treatment of hemobilia can be difficult and challenging.

AIM

To explore the causes of and treatment methods for hemobilia to improve its diagnosis and treatment.

METHODS

The clinical data, causes of bleeding, and treatment methods for six patients with hemobilia diagnosed at our hospital from 2014 to 2018 were analyzed, and the relevant literature was reviewed to summarize the diagnosis and treatment processes of hemobilia.

RESULTS

Of the six patients with hemobilia (including two females; mean age, 54.2 years), two had tumor lesions, one had gallbladder stones, one had gallbladder pseudoaneurysm, one underwent liver transplantation previously, and one had biliary tract infection; two were treated by surgery, one underwent endoscopic treatment, one underwent vascular intervention, and two were pharmacologically treated; five were cured, and one died from hemorrhagic shock.

CONCLUSION

Diagnosis and treatment of hemobilia are difficult and challenging. Improving the understanding of hemobilia, timely and meticulous examination, and reasonable selection of treatment methods are the keys to improving the diagnosis and treatment of hemobilia.

Hemobilia due to Hepatic artery pseudoaneurysm secondary to collateral circulation formation after liver trauma: a case report

Background

Hemobilia due to rupture of hepatic artery pseudoaneurysm and recurrent hemorrhage caused by hepatic artery collateral circulation are both rare complications after liver trauma. There have been a number of separate reports of both complications, but no cases have been reported in which the two events occurred in the same patient. Here we report a recurrent hemorrhage in the bile duct due to hepatic artery pseudoaneurysm secondary to collateral circulation formation after hepatic artery ligation in a patient with liver trauma.

Case presentation

A 52-year-old male patient was admitted to our hospital for liver trauma (Grade IV according to the American Association for the Surgery of Trauma (AAST) grading system) with active bleeding after a traffic accident. Hepatic artery ligation was performed for hemostasis. Three months after the surgery, the patient was readmitted for melena and subsequent hematemesis. Selective angiography examination revealed the formation of collateral circulation between the superior mesenteric artery and right hepatic artery. Moreover, a ruptured hepatic artery pseudoaneurysm was observed and transcatheter arterial embolization (TAE) was performed for hemostasis at the same time. After the treatment, the patient recovered very well and had an uneventful prognosis until the last follow-up.

Conclusion

For patients with hepatic trauma, the selection of the site of hepatic artery ligation and the diagnosis and treatment methods of postoperative biliary hemorrhage are crucial for the prognosis of the disease.

Endovascular treatment of a rare case of haemobilia caused by both pseudoaneurysm and a giant hepatic haemangioma

Haemobilia is defined as bleeding from the biliary system due to abnormal communication between a blood vessel and the bile ducts. Melena or hematemesis, abdominal pain and jaundice represent the pathognomonic triad for haemobilia, but clinical presentation and aetiology of this entity are extremely variable. We report a case of a 50-year-old man with melena and anaemia and a clinical history of multivalvular endocarditis in which an extremely rare presence of 2 uncommon causes of haemobilia was found, such as a mycotic pseudoaneurysm and a giant hepatic haemangioma, both treated by transarterial embolization. In the management of haemobilia, TAE has been proven to be the treatment of choice because it combines a diagnostic angiography with therapeutic intervention in a minimally invasive, safe and effective way. Physician and radiologist should keep in mind also the uncommon aetiologies of haemobilia, knowing that the source of bleeding could be more than just one.

Step-by-step Vascular Control for Extracapsular Resection of Complex Giant Liver Hemangioma Involving the Inferior Vena Cava

Massive hemorrhage remains an important clinical problem in extracapsular resection of giant liver hemangiomas (GLHs), especially for those involving the proximal hepatic veins and/or inferior vena cava. Between July 2004 and March 2012, 87 patients with a complex GLH scheduled for surgical treatment were included in this study. All patients were underwent vascular preparation (Step 1), advanced hepatic artery clamping (Step 2), and stepwise vascular occlusion (Step 3). Intraoperative blood loss, blood transfusion volume, degree of ischemia–reperfusion injury, and postoperative complications were recorded. No patients required urgent vascular preparation to manage intraoperative bleeding. In total, 87, 64, and 21 patients had portal triad (PT), infra-hepatic inferior vena cava (IVC), and suprahepatic IVC preparation; and 17, 43, and 11 patients had PT, PTand suprahepatic IVC, and all three (PT, infra-, and suprahepatic IVC) occlusions. The PT, infrahepatic IVC, and SIVC occlusion times were 12.1 ± 3.7 minutes, 7.9 ± 2.4 minutes, and 3.2 ± 1.4 minutes, respectively. Mean blood loss was 291.9 ± 124.5 mL, and only four patients received blood transfusions. No patients had life-threatening complications or died (Clavien-Dindo Grade 4, 5). Compared with paralleled studies, this technique has an advantage to decrease the blood loss in less liver ischemia time. For complex GLH resections, the described step-by-step vascular control technique was efficacious and feasible for controlling intraoperative bleeding.

Risk factors and management of different types of biliary injuries in blunt abdominal trauma: Single-center retrospective cohort study

Background

Biliary injuries after blunt abdominal traumas are uncommon and difficult to be predicted for early management. The aim of this study is to analyze the risk factors and management of biliary injuries with blunt abdominal trauma.

Method

Patients with blunt liver trauma in the period between 2009 to May 2019 were included in the study. Patients were divided into 2 groups for comparison; a group of liver parenchymal injury and group with traumatic biliary injuries (TBI).

Results

One hundred and eight patients had blunt liver trauma (46 patients with liver parenchymal injury and 62 patients with TBI). TBI were; 55 patients with bile leak, 3 patients with haemobilia, and 4 patients with late obstructive jaundice. Eight patients with major bile leak and 12 patients with minor bile leak had been resolved with a surgical drain or percutaneous pigtail drainage. Nineteen patients (34.5%) with major and minor bile leak underwent successful endoscopic retrograde cholangiopancreatography (ERCP). Sixteen patients (29.1%) underwent surgical repair for bile leak. In Multivariate analysis, the possible risk factors for prediction of biliary injuries were central liver injuries (P = 0.032), high grades liver trauma (P = 0.046), elevated serum level of bilirubin at time of admission (P = 0.019), and elevated gamma glutamyl transferase (GGT) at time of admission (P = 0.017).

Conclusion

High-grade liver trauma, central parenchymal laceration and elevated serum level of bilirubin and GGT are possible risk factors for the prediction of TBI. Bile leak after blunt trauma can be treated conservatively, while ERCP is indicated after failure of external drainage.

Risk factors and management of different types of biliary injuries in blunt abdominal trauma: Single-center retrospective cohort study

Background

Biliary injuries after blunt abdominal traumas are uncommon and difficult to be predicted for early management. The aim of this study is to analyze the risk factors and management of biliary injuries with blunt abdominal trauma.

Method

Patients with blunt liver trauma in the period between 2009 to May 2019 were included in the study. Patients were divided into 2 groups for comparison; a group of liver parenchymal injury and group with traumatic biliary injuries (TBI).

Results

One hundred and eight patients had blunt liver trauma (46 patients with liver parenchymal injury and 62 patients with TBI). TBI were; 55 patients with bile leak, 3 patients with haemobilia, and 4 patients with late obstructive jaundice. Eight patients with major bile leak and 12 patients with minor bile leak had been resolved with a surgical drain or percutaneous pigtail drainage. Nineteen patients (34.5%) with major and minor bile leak underwent successful endoscopic retrograde cholangiopancreatography (ERCP). Sixteen patients (29.1%) underwent surgical repair for bile leak. In Multivariate analysis, the possible risk factors for prediction of biliary injuries were central liver injuries (P = 0.032), high grades liver trauma (P = 0.046), elevated serum level of bilirubin at time of admission (P = 0.019), and elevated gamma glutamyl transferase (GGT) at time of admission (P = 0.017).

Conclusion

High-grade liver trauma, central parenchymal laceration and elevated serum level of bilirubin and GGT are possible risk factors for the prediction of TBI. Bile leak after blunt trauma can be treated conservatively, while ERCP is indicated after failure of external drainage.

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In most of the published series they discussed the iatrogenic biliary injuries or injuries after sharp trauma.

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To our knowledge it is the largest series to discuss the biliary injuries with blunt liver trauma.

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We can predict the possible risk factors for bile duct injury after blunt liver trauma.

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So we can diagnose and treat it properly and early before sepsis and biliary complications.

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We can approach to the ideal treatment modality for each type of biliary injuries with prober timing.

Hemobilia: Historical overview, clinical update, and current practices

Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosis of hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.

Biliary tract bleeding with obstructive jaundice after endoscopic ultrasound-guided fine-needle aspiration of a pancreatic head tumor

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe procedure and extraintestinal bleeding after EUS-FNA is rare. Two cases of biliary tract bleeding after EUS-FNA was reported, but no case of biliary hemorrhage with obstructive jaundice after EUS-FNA of pancreatic head tumor has been reported. We discuss one such case, the pitfalls encountered during EUS-FNA and how they were overcome.

CASE PRESENTATION

A 78-year-old man suspected of pancreatic head cancer was introduced to our hospital for pathological examination by EUS-FNA. Because he took antithrombotic drugs, we performed EUS-FNA after withdrawal of the drugs and replacement by heparin. The next day after EUS-FNA, obstructive jaundice was suspected by hematologic examination. Endoscopic retrograde cholangio-pancreatography was carried out and biliary tract bleeding was observed. We diagnosed obstructive jaundice due to hemobilia and inserted an endonasal biliary drainage tube. During the following period, the bleeding stopped and total bilirubin decreased. On the 15th hospital day, he was transferred to another hospital for pre-operative examination.

CONCLUSION

Biliary tract bleeding after EUS-FNA is quite rare but endosonographers must appreciate and deal appropriately with this adverse event.

Case Report: Spontaneous Resolution of Intracavitary Hepatic Artery Pseudoaneurysm Caused by Amebic Liver Abscess following Percutaneous Drainage

Intrahepatic pseudoaneurysm (IHPA) is generally iatrogenic, and it warrants urgent management because of its reportedly significant risk of rupture leading to considerable mortality. Intrahepatic pseudoaneurysm caused by amebic liver abscess (ALA) is exceedingly rare with fewer than seven published reports. All reported symptomatic cases have been treated with hepatic artery embolization; therefore, little is known about its natural course and effect of abscess drainage on its outcome. We report the first case of symptomatic intracavitary IHPA caused by ALA in which ultrasound-guided percutaneous catheter drainage of the abscess resulted in the spontaneous resolution of the IHPA.

Hemobilia: Etiology, diagnosis, and treatment☆

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon but important cause of gastrointestinal hemorrhage. Reports of hemobilia date back to the 1600s, but due to its relative rarity and challenges in diagnosis, only in recent decades has hemobilia been more critically studied. The majority of cases of hemobilia are iatrogenic and caused by invasive procedures involving the liver, pancreas, bile ducts and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other leading causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described (i.e. Quincke's triad), but this is present in only 25%-30% of patients with hemobilia. Therefore, prompt diagnosis depends critically on having a high index of suspicion, which may be based on a patient's clinical presentation and having recently undergone (peri-) biliary instrumentation or other predisposing factors. The treatment of hemobilia depends on its severity and suspected source and ranges from supportive care to advanced endoscopic, interventional radiologic, or surgical intervention. Here we provide a clinical overview and update regarding the etiology, diagnosis, and treatment of hemobilia geared for specialists and subspecialists alike.

Hemobilia: Perspective and Role of the Advanced Endoscopist

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon cause of gastrointestinal hemorrhage. Hemobilia has been documented since the 1600s, but due to its relative rarity, it has only been more critically examined in recent decades. Most cases of hemobilia are iatrogenic and caused by procedures involving the liver, pancreas, bile ducts, and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other major causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described, but this is present in only 25-30% of patients with hemobilia. Historically, the gold standard for diagnosis and treatment has been angiography and interventional radiologic intervention, respectively. However, the paradigm is shifting, at least in select cases, towards first-line reliance on noninvasive imaging (e.g., computed tomography) and therapeutic endoscopy, owing to advances in and the less invasive nature of both, while saving interventional radiological and/or surgical intervention for refractory or imminently life-threatening cases.

Gastrodoudenal Embolization: Indications, Technical Pearls, and Outcomes

The gastroduodenal artery (GDA) is frequently embolized in cases of upper GI bleed that has failed endoscopic therapy. Additionally, it may be done for GDA pseudoaneurysms or as an adjunctive procedure prior to Yttrim-90 (Y90) treatment of hepatic tumors. This clinical review will summarize anatomy and embryology of the GDA, indications, outcomes and complications of GDA embolization.

Recurrent Hemobilia Due to Right Hepatic Artery Pseudoaneurysm

Hemobilia is a potentially life-threatening clinical issue, the etiology of which iatrogenesis is playing increasingly more prominent role. Nowadays the most frequent etiology of hemobilia has shifted toward iatrogenesis owing to increasingly more frequent performance of liver procedures, either open or minimally invasive. Here we report a rare case of recurrent hemobilia after transarterial embolization. A man, aged 57 years, presented with Quincke's triad after cholecystectomy. Computed tomography imaging revealed a pseudoaneurysm of the right hepatic artery. Transarterial embolization failed, and hemobilia recurred. The patient underwent open ligation of the right hepatic artery. Transarterial embolization is a definitive treatment of hemobilia due to vascular issues. The choice of embolizing agent is crucial in transarterial embolization.

Arterio-biliary fistulas: What to choose as endovascular treatment?

Objectives Endovascular procedures are the treatment of choice in cases of intrahepatic fistulas. Arterio-biliary fistulas are the rarest and most difficult to treat, due to high risk of infection. Methods Eight cases of persistent hemobilia that developed as a result of arterio-biliary fistulas are presented. Five cases developed as a result of iatrogenic injury, two cases as a result of chronic infection, one case as a consequence of trauma. Results Patients were treated using endovascular embolization or combined endovascular and endoscopic biliary tract revision. The results were monitored after six to seven days and one month after embolization. The embolizations were considered effective in all cases. One patient had four asynchronous fistulas requiring separate treatments sessions. Four patients required a revision of their biliary ducts after embolization and restoration of patency. In one patient, a migration of the coil to biliary ducts occurred. Conclusion Endovascular treatment of arterio-biliary fistulas is safe and effective. The use of embolization with soft and biodegradable materials like histoacrylic glue or thrombin may be the optimal method of treatment in comparison with coils which have a risk of migration or chronic infection.

Hemobilia: An Uncommon But Notable Cause of Upper Gastrointestinal Bleeding

GOAL AND BACKGROUND

A literature review to improve practitioners' knowledge and performance concerning the epidemiology, diagnosis, and management of hemobilia.

STUDY

A search of Pubmed, Google Scholar, and Medline was conducted using the keyword hemobilia and relevant articles were reviewed and analyzed. The findings pertaining to hemobilia etiology, investigation, and management techniques were considered and organized by clinicians practiced in hemobilia.

RESULTS

The majority of current hemobilia cases have an iatrogenic cause from either bile duct or liver manipulation. Blunt trauma is also a significant cause of hemobilia. The classic triad presentation of right upper quadrant pain, jaundice, and upper gastrointestinal bleeding is rarely seen. Computed tomography and magnetic resonance imaging are the preferred diagnostic modalities, and the preferred therapeutic management includes interventional radiology and endoscopic retrograde cholangiopancreatography. Surgery is rarely a therapeutic option.

CONCLUSIONS

With advances in computed tomography and magnetic resonance imaging technology, diagnosis with these less invasive investigations are the favored option. However, traditional catheter angiography is still the gold standard. The management of significant hemobilia is still centered on arterial embolization, but arterial and biliary stents have become accepted alternative therapies.

Iatrogenic hemobilia: imaging features and management with transcatheter arterial embolization in 30 patients

PURPOSE

We aimed to evaluate the imaging features of computed tomography (CT) and angiography and the efficacy of transcatheter arterial embolization (TAE) in patients with hemobilia of different iatrogenic causes.

METHODS

Thirty patients with hemobilia were divided into two groups according to their iatrogenic causes, i.e., group 1, 11 patients (36.7%) with transhepatic intervention and group 2, 19 patients (63.3%) with surgical procedures in the hilar area. Seventeen patients (56.7%) underwent abdominal contrast-enhanced CT before selective angiography. Polyvinyl alcohol particles, gelatin sponges, and coils were used for TAE. Data from the two groups were compared using Fisher's exact test and the Mann-Whitney U test.

RESULTS

Contrast-enhanced CT showed a hematoma, extravasation of contrast material, and pseudoaneurysm. The bleeding source was determined by angiographic features in all patients, which were not significantly different between the two groups (P = 0.127), and pseudoaneurysm was the most common. The embolic material and number of coils used for TAE were significantly different between the two groups (P < 0.001), but the embolization was technically successful in all patients. The clinical success rate of the first embolization was 100% in group 1 vs. 84.2% in group 2. The overall clinical success rate of TAE was 100% in all patients. The complication rate was 63.6% in group 1 vs. 68.4% in group 2 (P = 1.000).

CONCLUSION

CT was useful in diagnosing hemobilia, and angiograms enabled determination of the bleeding source. Pseudoaneurysm was one of the most common angiographic features. TAE was successfully performed with different embolic materials on the basis of the iatrogenic cause and bleeding location.

Hemobilia following laparoscopic cholecystectomy: computed tomography findings and clinical outcome of transcatheter arterial embolization

BACKGROUND

Hemobilia following laparoscopic cholecystectomy (LC) can occur in the early or late postoperative course and poses a diagnostic and therapeutic challenge.

PURPOSE

To assess computed tomography (CT) findings and clinical outcomes after transcatheter arterial embolization (TAE) in patients presenting with hemobilia following LC.

MATERIAL AND METHODS

Fourteen patients treated for hemobilia following LC were included in the study. Three patients were diagnosed by endoscopy and 11 by abdominal contrast-enhanced CT. Coils or microcoils were superselectively deployed to occlude the bleeding vessel during TAE. Abdominal CT findings of hemobilia, and the success rate and complication of TAE were observed.

RESULTS

Abdominal CT provided the following signs of hemobilia: hematoma within the abdominal cavity and gallbladder fossa, blood clots containing high attenuation within the bile duct, biliary dilatation, pseudoaneurysm of the right hepatic artery, contrast extravasation, enhancement of the bile duct wall, and hypoperfusion of the right lobe. The success rate of TAE was 100% and rebleeding did not occur in any patient. Post-embolization syndrome and hepatic ischemia occurred in nine patients, which was associated with age and the time interval between the LC and TAE.

CONCLUSION

Abdominal CT provided direct signs that can aid in the diagnosis of hemobilia after LC. TAE allowed for successful treatment of hemobilia with minor complications.

Hemobilia After Laparoscopic Cholecystectomy: Imaging Features and Management of an Unusual Complication

PURPOSE

To assess the imaging features and the management of hemobilia after laparoscopic cholecystectomy (LC).

MATERIALS AND METHODS

A total of 12 patients who were treated for hemobilia after LC were included in the study. Selective arteriography was performed to find the bleeding artery. Coils or microcoils were deployed superselectively to occlude the bleeding branch. The clinical course, imaging findings, the embolic effect, complications, and follow-up were evaluated.

RESULTS

Risk factors for hemobilia included a variant ductal anatomy, a variant cystic artery, and intraoperative adhesion. Abdominal computed tomography (CT) could provide the diagnostic signs as follows: a hematocele in the abdominal cavity, the gallbladder fossa, and the bile duct, biliary dilation, pseudoaneurysm of the right hepatic artery, and contrast extravasations on contrast-enhanced CT. No rebleeding occurred after the transcatheter arterial embolization in all patients without immediate procedural complications.

CONCLUSIONS

Gallbladder triangle anatomic variation and intraoperative adhesion were the risk factors for hemobilia after LC. Abdominal CT is a useful examination for the diagnosis. Transcatheter arterial embolization is the therapeutic option of choice.

Hemobilia

Hemobilia is a rare source of upper gastrointestinal bleeding, though the incidence is increasing along with the rise in minimally invasive biliary interventions. Prompt diagnosis and treatment rests on having appropriate clinical suspicion which should be based on the patient's presenting signs and symptoms, as well as history including recent instrumentation. Endoscopy should be reserved for cases of upper gastrointestinal bleeding with low suspicion for hemobilia. Interventional radiology may be the first-line diagnostic and therapeutic option for patients with a high suspicion of hemobilia. While embolization is the mainstay of therapy, other options include thrombin injection, stent placement, and/or placement of a percutaneous biliary drain. Surgery should be reserved for failed treatment by interventional radiology.

Gastrointestinal bleeding and obstructive jaundice: Think of hepatic artery aneurysm

Hemobilia is an uncommon and potential life-threatening condition mainly due to hepato-biliary tree traumatic or iatrogenic injuries. Spontaneously ruptured aneurysm of the hepatic artery is seldom described. We report the case of an 89-year-old woman presenting with abdominal pain, jaundice and gastrointestinal bleeding, whose ultrasound and computed tomography revealed a non-traumatic, spontaneous aneurysm of the right hepatic artery. The oeso-gastro-duodenoscopy and colonoscopy did not reveal any bleeding at the ampulla of Vater, nor anywhere else. Selective angiography confirmed the diagnosis of hepatic artery aneurysm and revealed a full hepatic artery originating from the superior mesenteric artery. The patient was successfully treated by selective embolization of microcoils. We discuss the etiologies of hemobilia and its treatment with selective embolization, which remains favored over surgical treatment. Although aneurysm of the hepatic artery is rare, especially without trauma, a high index of suspicion is needed in order to ensure appropriate treatment.

Transarterial catheter embolisation for an unusual cause of upper gastrointestinal haemorrhage

A 72-year-old man with a history of gallstones, and complex cardiac and endocrinological comorbidities, presented with severe abdominal pain and melaena. CT mesenteric angiogram showed a cystic artery pseudoaneurysm and gallbladder distended by haematoma. Subsequent mesenteric angiography confirmed a cystic artery pseudoaneurysm, which was successfully embolised with microcoils. The patient made a rapid recovery and was discharged after 3 days.

Management of blunt liver injury: what is new?

Nonoperative management has become the surgical treatment of choice in the hemodynamically stable patient with blunt hepatic trauma. The increased use and success of nonoperative management have been facilitated by the development of increasingly higher resolution computed tomography imaging, improved management of physiology and resuscitation (damage control), and routine availability of interventional procedures such as angiography and embolization, image-guided percutaneous drainage, and endoscopy. On the other hand, recognition of the patient who should proceed to immediate laparotomy is of utmost importance. A systematic and logical approach to the control of hemorrhage is required in the operating room. Thorough knowledge of the anatomy and surgical techniques, such as perihepatic packing, effective Pringle maneuver, hepatic mobilization, infrahepatic and suprahepatic control of the IVC, and stapled hepatectomy, is essential.

Three complications of Pair (puncture, aspiration, injection, reaspiration) in one case: Recurrent hemobilia, cyst infection and pneumonia

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Percutaneous aspiraton injection and reaspiration technique can have multiple complications like cysts infection, pneumonia and hematobilia.

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Hematobilia is a rare complication; however, early diagnosis is the key feature.

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When complicated, treatment procedure can be challenging with elonged hospital stay and multiple other investigations like ERCP.

Introduction

With the appropriate indications, puncture, aspiration, injection and reaspiration (PAIR) is the most effective minimal invasive method used in the treatment of hydatic cysts. Hemobilia is the hemorrhagia in bile ducts in consequence of any reason. In literature there is no case with hemobilia because of PAIR. This is the first case with recurrent hemobilia, infection in cyst cavity and pneumonia because of PAIR.

Case

A 66 years old female patient was admitted to hospital with complaints of abdominal pain, hematemesis and melaena. She gave the history of PAIR for two hydatic cysts. At physical examination, there were jaundice, tenderness at right subcostal area and melaena at rectal digital examination. Hemobilia was detected by abdominal ultrasonography and magnetic resonance cholangiopancreaticography (MRCP). An endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy were performed. The patient was discharged after 6 days hospital stay. One day after the discharge the patient was admitted to hospital with the same complaints again. Performing ERCP and balloon extraction, the hematoma filling the common bile duct was removed. After the patient was hemodynamically stable for 3 days, she was discharged from the hospital. A week after that the patient was admitted to hospital with the clinical findings of infected hydatic cyst and pneumonia. The patient was treated medically with mechanical ventilation support for 8 days.

Conclusion

It should not be underestimated that, there can be serious complications of PAIR like hemobilia. Therefore, PAIR should be performed only in centers having appropriate medical and surgical facilities.

Combined interventional radiology followed by endoscopic therapy as a single procedure for patients with failed initial endoscopic biliary access

BACKGROUND

Percutaneous transhepatic cholangiography (PTC) assisted endoscopic retrograde cholangiopancreatography (ERCP) usually requires two separate sessions. There are no reports to support performing the procedures in a single session.

AIM

The purpose of this study was to assess the feasibility and safety of the ERCP rendezvous technique via PTC in a single session for patients with initially failed endoscopic biliary intervention.

METHOD

We conducted a retrospective cohort study in a high volume tertiary referral center. A single experienced endoscopist and two interventional radiologists performed all the procedures. Patient demographics and all the related clinical data from January 2009 to July 2011 were obtained from hospital records. Outcome measures were the overall success rates of completion of the combined PTC and ERCP sessions for biliary drainage. Procedure-related complications (bleeding, perforation, hemobilia, bile leak, pancreatitis or cholangitis) were also assessed.

RESULT

Twenty-three patients (14 men) with a median age of 68 years (range 47-89 years) underwent 26 combined PTC-ERCP as a single procedure. PTC and ERCP were both performed within 6 h of failed ERCP in 19 cases (73 %) and the others within 72 h. A total of 91 % of patients had underlying gastrointestinal metastatic cancers, and a surgically altered pancreaticobiliary system was found in 26 % of patients. Percutaneous biliary access was obtained via PTC in all procedures and successful rendezvous therapy was performed in 23 cases (88 %), which include biliary stone removal with a balloon catheter (n = 7) and biliary prostheses (n = 19). The median procedure length for successful PTC-ERCP rendezvous was 60 min (range 14-147 min). With the mean follow-up of 202 days (range 8-833 days), three immediate procedural complications [asymptomatic pneumoperitoneum (n = 2) and post biliary sphincterotomy bleeding (n = 1)] and two delayed complications (a hemorrhagic shock from a damaged branch of hepatic artery and a biloma with secondary infection) occurred, and there was no procedure-associated mortality.

CONCLUSION

This is the first report assessing the feasibility and safety of a combined procedure of ERCP and PTC in a single session. In experienced hands, the combined approach in a single session is appropriate in selected patients with an acceptable risk.

Upper gastrointestinal bleeding: A rare complication of acute cholecystitis

INTRODUCTION

Haemobilia is a rare complication of acute cholecystitis and may present as upper gastrointestinal bleeding.

PRESENTATION OF CASE

We describe two patients with acute cholecystitis presenting with upper gastrointestinal bleeding due to haemobilia. Bleeding from the duodenal papilla was seen at endoscopy in one case but none in the other. CT demonstrated acute cholecystitis with a pseudoaneurysm of the cystic artery in both cases. Definitive control of intracholecystic bleeding was achieved in both cases by embolisation of the cystic artery. Both patients remain symptom free. One had subsequent laparoscopic cholecystostomy and the other no surgery.

DISCUSSION

Pseudoaneurysms of the cystic artery are uncommon in the setting of acute cholecystitis. OGD and CT angiography play a key role in diagnosis. Transarterial embolisation (TAE) is effective in controlling bleeding. TAE followed by interval cholecystectomy remains the treatment of choice in surgically fit patients.

CONCLUSION

We highlight an unusual cause of upper GI haemorrhage. Surgeons need to be aware of this rare complication of acute cholecystitis. Immediate non-surgical management in these cases proved to be safe and effective.

[Massive bleeding hemobilia occurred in patient with hepatocellular carcinoma]

Massive bleeding hemobilia occurs rarely in patients with hepatocellular carcinoma (HCC) without any invasive procedure. Upper gastrointestinal bleeding in patient with cirrhosis and abdominal pain with progressive jaundice in patient with HCC were usually thought as variceal bleeding and HCC progression respectively. We experienced recently massive bleeding hemobilia in patient with HCC who was a 73-year old man and showed sudden abdominal pain, jaundice and hematochezia. He had alcoholic cirrhosis and history of variceal bleeding. One year ago, he was diagnosed as HCC and treated with transarterial chemoembolization periodically. Sudden right upper abdominal pain occurred then subsided with onset of hemotochezia. Computed tomography showed bile duct thrombosis spreading in the intrahepatic and extrahepatic ducts, while an ampulla of vater bleeding was observed during duodenoscopy. Hemobilia could be one of the causes of massive bleeding in patients with cirrhosis and HCC especially when they had sudden abdominal pain and abrupt elevation of bilirubin.

Hepatic arteriovenous fistulae: role of interventional radiology

INTRODUCTION

Hepatic arterial venous fistulae are abnormal communications between the hepatic artery and portal or hepatic vein and commonly occur either secondary to iatrogenic causes like liver biopsy, transhepatic biliary drainage, transhepatic cholangiogram and surgery, or following mechanical insult like blunt or penetrating trauma. Congenital fistulae are rare. Treatment is warranted as an emergency management or in the development of portal hypertension/heart failure in chronic cases. Both surgical and endovascular occlusion of the fistula can be attempted with the latter carrying low intra and post-procedure morbidity. Endovascular treatment has thus currently emerged as a minimally invasive reliable treatment option in such individuals.

METHODS AND RESULTS

We describe a short series consisting of four cases of acquired hepatic arterioportal/venous fistulae, which were referred to interventional radiology for endovascular management over the last 2 years. Three patients had arterio-portal communication and one patient had communication between the hepatic artery and middle hepatic vein. Successful embolization through the transarterial route was achieved in all four patients. A brief discussion of these cases is presented along with a relevant review of literature.

CONCLUSIONS

Endovascular techniques currently form less invasive and first line treatment options in arterioportal/venous fistulae, surgery being reserved only for unsuccessful embolizations/complex fistulae.

Etiology, clinical features, and endoscopic management of hemobilia: a retrospective analysis of 37 cases

BACKGROUND/AIMS

Hemobilia is a rare cause of upper gastrointestinal bleeding. Endoscopic retrograde cholangiopancreaticography (ERCP) is considered to be an excellent diagnostic and treatment modality. Thirty-seven cases of hemobilia with different underlying pathologies were analyzed to illustrate clinical features and to evaluate the role of endoscopic management.

METHODS

A total of 37 patients (26 men and 11 women; mean age, 66.2±15.3 years) who were confirmed to have hemobilia by ERCP in a single center from 2000 to 2010 were reviewed retrospectively. Patients with iatrogenic causes of hemobilia were excluded in this study.

RESULTS

The causes of hemobilia were hepatocellular carcinoma in 14, bile duct and gallbladder malignancies in 12, common bile duct stones with cholangitis in 4, acute cholecystitis in 4, and pancreatic cancer in 2 patients. The clinical features of hemobilia were jaundice (89.2%), abdominal pain (78.4%), and melena (13.5%). The cholangiographic findings of hemobilia were amorphous filling defects in 15, tubular filling defects in 6, and cast-like filling defects in 6 patients. Endoscopic management included endoscopic nasobiliary drainage in 26 patients and endoscopic retrograde biliary drainage in 7 patients. Biliary obstruction caused by hemobilia was successfully treated with endoscopic biliary drainages in most cases.

CONCLUSIONS

The most common non-iatrogenic causes of hemobilia were hepatobiliary malignancies, and the majority of patients presented with jaundice and abdominal pain. Endoscopic biliary drainage is recommended as the initial management to control biliary obstruction.

Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of the literature

OBJECTIVE

Hemobilia is an uncommon cause of gastrointestinal bleeding. The etiology is diverse, but most often, it is iatrogenic. The present study aims to reassess the clinical picture and the treatment of choice.

METHODS

We describe a case series from a single center of patients who presented with nontraumatic iatrogenic hemobilia.

RESULTS

Over a period of 8 years, hemobilia occurred in 12 patients: following liver biopsy in six patients and after endoscopic biliary interventions in four patients, with a respective prevalence of 0.1 and 0.04%. The clinical presentation was characterized by an upper gastrointestinal bleeding (n=11) and/or biochemical signs of sudden biliary obstruction (n=9). The onset of the symptoms occurred after a median of 6 days (range: 1-23). Ultrasound and computed tomography scan missed the diagnosis in, respectively, 4/5 and 2/5 of patients. On arteriography, pseudoaneurysm (6/12) was the most common finding. Transcatheter arterial embolization controlled the bleeding in all cases (12/12) without major complications.

CONCLUSION

The delay between the intervention and the clinical presentation and the fact that imaging studies may fail to diagnose hemobilia may mislead the physician. Transcatheter arterial embolization is the treatment of choice for hemobilia. It has proven to be effective and safe and it offers a long-term definitive cure.

Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review

AIM

To assess the published evidence on the endovascular treatment of non-variceal upper gastrointestinal haemorrhage.

MATERIALS AND METHODS

An Ovid Medline search of published literature was performed (1966-2009). Non-English literature, experimental studies, variceal haemorrhage and case series with fewer than five patients were excluded. The search yielded 1888 abstracts. Thirty-five articles were selected for final analysis.

RESULTS

The total number of pooled patients was 927. The technical and clinical success of embolization ranged from 52-100% and 44-100%, respectively. The pooled mean technical/clinical success rate in primary upper gastrointestinal tract haemorrhage (PUGITH) only, trans-papillary haemorrhage (TPH) only, and mixed studies were 84%/67%, 93%/89%, and 93%/64%, respectively. Clinical outcome was adversely affected by multi-organ failure, shock, corticosteroids, transfusion, and coagulopathy. The anatomical source of haemorrhage and procedural variables did not affect the outcome. A successful embolization improved survival by 13.3 times. Retrospective comparison with surgery demonstrated equivalent mortality and clinical success, despite embolization being applied to a more elderly population with a higher prevalence of co-morbidities.

CONCLUSIONS

Embolization is effective in this very difficult cohort of patients with outcomes similar to surgery.

Hemobilia

Hemobilia is an uncommon medical problem that presents in a varied fashion and is increasingly of iatrogenic origin. The diagnosis of hemobilia needs to be considered in patients presenting with upper gastrointestinal bleeding, particularly if they are jaundiced with abdominal pain in the setting of recent or previous percutaneous liver intervention or abdominal trauma. Multislice computed tomographic angiography is increasingly being used in the investigation, but transcatheter arterial embolization remains the cornerstone of managing those patients requiring intervention. The majority of patients with hemobilia will be managed supportively or with radiologic intervention; most do not require surgical intervention.

Hemobilia due to hepatic artery aneurysm as the presenting sign of fibro-muscular dysplasia

Fibro-muscular dysplasia (FMD) is a rare but well documented disease with multiple arterial aneurysms. The patients, usually women, present with various clinical manifestations according to the specific arteries that are affected. Typical findings are aneurysmatic dilatations of medium-sized arteries. The renal and the internal carotid arteries are most frequently affected, but other anatomical sites might be affected too. The typical angiographic picture is that of a "string of beads". Common histological features are additionally described. Here we present a case of a 47-year-old woman, who was hospitalized due to intractable abdominal pain. A routine work-up revealed a liver mass near the portal vein. Before a definite diagnosis was reached, the patient developed massive upper gastrointestinal bleeding. In order to control the hemorrhage, celiac angiography was performed revealing features of FMD in several arteries, including large aneurysms of the hepatic artery. Active bleeding from one of these aneurysms into the biliary tree indicated selective embolization of the hepatic artery. The immediate results were satisfactory, and the 5 years follow-up revealed absence of any clinical symptoms.