Carcinoma of the pancreas presenting with hemobilia

Massive hemobilia: a diagnostic and therapeutic challenge

BACKGROUND

Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. In this retrospective analysis, we have evaluated the challenges involved in the diagnosis and management of massive hemobilia.

METHODS

Between 2001 and 2011, a total of 20 consecutive patients (14 males) who were treated in our department for massive hemobilia were included in the study and their records were retrospectively analyzed.

RESULTS

Causes of hemobilia were blunt liver trauma (n = 9), hepatobiliary intervention (n = 4), post-laparoscopic cholecystectomy hepatic artery pseudoaneurysm (n = 3), hepatobiliary tumors (n = 3), and vascular malformation (n = 1). Melena, abdominal pain, hematemesis, and jaundice were the leading symptoms. All patients had undergone upper GI endoscopy, abdominal ultrasound, and computerized tomography of the abdomen. An angiogram and therapeutic embolization were done in 12 patients and was successful in nine but failed in three, requiring surgery. Surgical procedures performed were right hepatectomy (n = 4), extended right hepatectomy (n = 1), segmentectomy (n = 1), extended cholecystectomy (n = 1), repair of the pseudoaneurysm (n = 3), and right hepatic artery ligation (n = 1).

CONCLUSION

The successful diagnosis of hemobilia depends on a high index of suspicion for patients with upper GI bleeding and biliary symptoms. Although transarterial embolization is the therapeutic option of choice for massive hemobilia, surgery has a definitive role in patients with hemodynamic instability, after failed embolization, and in patients requiring laparotomy for other reasons.

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.

Cholecystitis caused by hemocholecyst from underlying malignancy

Massive hemobilia is a well recognized clinical entity, particularly when it presents with jaundice, GI bleeding, and biliary pain. However, occult hemobilia is more difficult to diagnose and has seldom been reported because of its clinically silent nature. In fact, this is usually overlooked until complications arise. Hemocholecyst or clot within the gallbladder may rarely occur in this setting, leading to cystic duct obstruction and cholecystitis. Most previous reports describe cholecystitis resulting from hemocholecyst after iatrogenic trauma. We describe two cases in which hemocholecyst occurred from underlying malignancies, both resulting in cholecystitis (acute or chronic).

Massive hemobilia and acalculous cholecystitis due to benign gallbladder polyp

A 37-year-old male with metachromatic leukodystrophy, a congenital cerebroside storage disease strongly associated with benign gallbladder polyps, presented with hemobilia and acalculous cholecystitis due to a long, slender, benign gallbladder polyp. This case report extends the clinical spectrum of gallbladder polyps and demonstrates a novel cause of hemobilia. The unusually long, slender polyp shape may have promoted hemorrhage due to the potential for torsion around a slender stalk. The mechanism of cholecystitis may have been cystic duct obstruction from blood clots or possibly from prolapse by the long, slender polyp into the cystic duct.

Villous adenomatosis of duct of Wirsung revealed by wirsungorragie: evolution and surgical management

A patient presenting with wirsungorragie was found to have a villous adenoma of the duct of Wirsung. The lesion was treated by a left pancreatectomy. Five years later he presented with recurrent wirsungorragie and was found to have a villous adenomatosis of the main pancreatic duct and of its side branches. This time a Whipple procedure was performed, achieving a total pancreatectomy. The patient has remained well for 12 months. This case of villous adenomatosis is, to our knowledge, the first one to be revealed by a wirsungorragie.