Hemobilia and other complications caused by percutaneous ultrasound-guided liver biopsy

Haemobilia as a primary presentation of cholangiocarcinoma

We present a case of haemobilia as a primary presentation for underlying cholangiocarcinoma. A man in his 50s initially presented to emergency with Quincke's triad, RUQ pain, jaundice and UGI bleeding. The initial diagnosis of haemobilia was made on endoscopic retrograde cholangiopancreatography (ERCP) on primary presentation, but the presence of blood and the recurrent clot obstruction of the biliary tract made the underlying diagnosis extremely difficult, resulting in the patient having 4 ERCP, 1 spyglass and multiple CTs and magnetic resonance cholangiopancreatography. Eventually, the patient underwent a Whipple's procedure without tissue diagnosis, confirming cholangiocarcinoma on histopathology. This case emphasises the difficulty of diagnosis of underlying malignancy in the setting of haemobilia, the benefit of multidisciplinary meeting discussions to support significant interventions and the need to be cautious and curious when managing atypical presentations.

Porto-biliary fistula as an uncommon cause of haemobilia: A case report and literature review

Background

Haemobilia is a rare cause of gastrointestinal bleeding. It can be related to iatrogenic injuries, inflammatory diseases, and, more recently, postoperative, or post-procedure complications. Porto-biliary fistula is an uncommon case of haemobilia and has been related to iatrogenic injury or chronic inflammatory processes. To date, less than 30 cases of Porto-biliary fistula have been reported.

Case presentation

We present a 53 years-old woman with a history of biliary obstruction due to a choledochal cyst that required hepaticojejunostomy with evidence of anastomotic stricture. A percutaneous transhepatic biliary drainage (PTBD) was performed, with 3 failed attempts of percutaneous dilatation. A new hepaticojejunostomy was completed, however, 45 days later the patient presented to the emergency room with haemobilia and secondary hemodynamic instability. An emergency damage control laparotomy was performed, achieving bleeding control. In the second procedure, there is evidence of an ulcerative injury of the biliary tract secondary to a Porto-biliary fistula.

Conclusion

Porto-biliary fistula is an entity that cannot be ruled out in cases of haemobilia, especially in cases with a history of bile duct surgical or percutaneous procedures. The prognosis is usually good if multidisciplinary management is performed, and the source of the bleeding is identified early.

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Portobiliary is a rare condition with increased risk of mortality.

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Clinical suspicion should be present in patients with multiple procedures in the bile tract.

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Multidisciplinary management increases the rate of successful management.

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Ureteroscopy could be an alternative to choledocoscopy in emergency context.

Hemobilia Caused by Arterioportal Fistula Following Percutaneous Liver Biopsy Complicated by Acute Cholecystitis and Review of the Literature

We present a case of a 44-year-old male with chronic hepatitis B that visited the Emergency Department due to epigastric pain after a liver biopsy. The ultrasonography revealed signs of bleeding in the bile ducts. and angiography visualized an arterioportal fistula. Selective right hepatic artery branch embolization was performed, and the bleeding was controlled. Although, the clinical picture was initially improved, the patient presented later with acute abdomen, obstructive jaundice and fever. The patient underwent cholecystectomy with bile duct exploration and placement of a Kehr's T tube in the common bile duct. The postoperative course was uneventful. We also review the relevant literature concerning arterioportal fistula manifested as hemobilia as well as acute cholecystitis occurring after hemobilia.

Rare cause of obstructive haemobilia with recurrent biliopancreatic complications: a paradigmatic case

Haemobilia is an unusual but significant cause of upper gastrointestinal bleeding. Two-thirds of haemobilia cases are secondary to invasive hepato-biliopancreatic procedures. Biliary angiodysplasia is exceptionally unusual, with only three cases reported. Herein, we report the case of an autonomous 80-year-old woman with a history of cholecystectomy 5 years ago and cardiovascular disease-hypertension, heart failure, acute myocardial infarction, stroke and non-valvular atrial fibrillation, anticoagulated with apixaban 2.5 mg two times per day. Since July 2019, she had four episodes of acute cholangitis of mild-to-moderate severity, having undergone broad spectrum antibiotics treatment and endoscopic retrograde cholangiopancreatography (ERCP), with sphincterotomy and bile sludge extraction. After 3 months, the patient presented with a new episode of acute cholangitis, this time with haemobilia (Quincke's triad). An abdominal CT angiography showed no evidence of active bleeding, with plastic biliary prosthesis left by ERCP. The patient continued presenting new episodes of acute cholangitis with haemobilia, some of them with associated pancreatitis. A cholangioscopy with Spyglass DS II was performed, showing an angiodysplasia occupying half of the luminal circumference of the middle choledoccus, without active haemorrhage. After a multidisciplinary meeting and given the high haemorrhagic/thrombotic risk (CHA2DS2-VASc 8), closure of the left atrial appendage was considered. However, relapse of the condition after beginning the antiaggregation protocol for cardiovascular intervention made it unfeasible. Another cholangioscopy with an ultra-thin endoscope for argon-plasma coagulation was attempted, without success. The abdominal CT angiography was repeated, this time with identification of dilated ramifications of the gastroduodenal and inferior pancreatic arteries. After embolisation of these aberrant vessels with microcoils, the patient went well, with no recurrence of bleeding or biliopancreatic complications. We present a case of obstructive haemobilia with multiple biliopancreatic complications, secondary to an extremely rare cause-choledochal angiodysplasia. Cholangioscopy had a decisive role in the diagnosis and therapeutic guidance. The diagnostic/therapeutic challenge associated with haemobilia stands out, with the need for a personalised and multidisciplinary approach.

Impact of risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy of space-occupying lesions

INTRODUCTION

Ultrasound-guided percutaneous liver biopsy is considered the technique of choice for the histological diagnosis of space-occupying lesions, given its high level of safety and diagnostic performance. However, since it is an invasive diagnostic procedure, complications can occur. Various clinical and radiological parameters have been analyzed as factors related with the efficacy of the technique or with its complications; however, the results have been contradictory. Thus, we aimed to evaluate the impact of various risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy in the diagnosis of space-occupying lesions in ordinary clinical practice.

MATERIAL AND METHODS

This retrospective observational study included all patients who underwent real-time ultrasound-guided percutaneous biopsies of space-occupying liver lesions with the free-hand technique between December 2012 and February 2018 in the diagnostic imaging department at the Hospital Clínico Universitario de Santiago de Compostela. We analyzed the following risk factors: location of the lesion in upper liver segments (II, IVa, VII, or VIII); proximity to the liver capsule, distance from the skin > 100mm, interposition of osseus or vascular structures, inability to go through healthy parenchyma, and lack of patient cooperation during the procedure. Efficacy was analyzed in terms of the number of cylinders obtained and the percentage of adequate biopsies; safety was analyzed in terms of the percentage of complications, which were classified as major or minor.

RESULTS

We included 295 biopsies in 278 patients (median age, 69 years; 64.1% male; 44.7% had prior neoplasms). In 61.4%, the biopsy was indicated for the initial diagnosis; 82.4% of biopsies were done in hospitalized patients, and 65% of the lesions were located in the right liver lobe. The median number of cylinders obtained was 3 (range 1-6); 91.2% of the biopsies were adequate and 92.2% were considered clinically useful. These percentages did not differ significantly according to the presence of risk factors. Complications occurred in 10 (3.4%) patients. Complications were considered major in 3 (0.9%) patients (2 (0.6%) bleeding complications and 1 (0.3%) infectious complication) and minor in 7 (2.4%). The percentage of complications was significantly higher in patients who did not cooperate during the procedure (p=0.04).

CONCLUSIONS

Ultrasound-guided percutaneous liver biopsy is an efficacious and safe technique for the histological diagnosis of space-occupying liver lesions. Our results confirm the increased rate of complications when patients fail to cooperate during the procedure.

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.

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 caused by pancreatic arteriovenous malformation: A case report and literature review

RATIONALE

Hemobilia caused by arteriovenous malformation is extremely rare but could be lethal. To date, most reports have been single-case reports, and no literature reviews are available.

PATIENT CONCERNS

A 47-year-old man presented to the emergency department with abdominal pain and fever. He complained of abdominal pain and weight loss for the past 2 months.

DIAGNOSES

Contrast-enhanced computed tomography and magnetic resonance imaging showed a heterogenous lesion located in pancreatic head and tumor was suspected.

INTERVENTIONS

Endoscopic retrograde cholangiopancreatography was performed and bleeding from papilla of Vater could be viewed. Nasobiliary drainage was placed to alleviate the pain and jaundice. Emergency laparotomy was performed due to the recurrence of severe pain and bleeding, and pancreatoduodenectomy was then performed. Macroscopic examination showed the ulceration connected with collected vessels which were located in pancreatic head and microscopic examination confirmed the presence of arteriovenous malformation.

OUTCOMES

The patient recovered uneventfully and was discharged 10 days after the surgery. He is asymptomatic on 4-month follow up.

LESSONS

Arteriovenous malformation is a rare cause of hemobilia, but it could lead to life threatening bleeding. Transarterial embolization could be effective to control the bleeding temporarily, however repeated hemorrhage may occur. Surgical resection may be a better option.

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.

Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments

Of all procedures in interventional radiology, percutaneous transhepatic biliary drainage (PTBD) is amongst the most technically challenging. Successful placement requires a high level of assorted skills. While this procedure can be life-saving, it can also lead to significant iatrogenic harm, often manifesting as bleeding. Readers of this article will come to understand the pathophysiology and anatomy underlying post-PTBD bleeding, its incidence, its varied clinical manifestations and its initial management. Additionally, a structured approach to its treatment emphasizing endovascular and percutaneous methods is given.

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.

Unexplained gastrointestinal bleed due to arteriobiliary fistula after percutaneous liver biopsy

We represent a case of a 54-year-old male who presented to the emergency department with right upper quadrant abdominal pain and melena three weeks after percutaneous liver biopsy. He was found to have anemia secondary to an upper gastrointestinal hemorrhage, unresponsive to multiple blood transfusions. Angiography later revealed an arteriobiliary fistula with contrast extravasation entering the duodenum. The fistula was successfully embolized and the patient was discharged without complication. This report demonstrates the importance in considering a vascular intrahepatic fistula in patients with right upper quadrant abdominal pain after remote liver biopsy.

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.

The clinical value of hepatic extracellular volume fraction using routine multiphasic contrast-enhanced liver CT for staging liver fibrosis

AIM

To investigate the value of hepatic extracellular volume fractions (fECVs) measured using routine liver computed tomography (CT) evaluating liver fibrosis (LF).

MATERIALS AND METHODS

A total of 60 patients (male:female ratio, 39:21; mean age, 42.4 years) histologically diagnosed with LF underwent routine liver CT. Absolute enhancement (in Hounsfield units) of the liver parenchyma (E_liver) and aorta (E_aorta) 3 minutes after contrast medium administration was calculated using precontrast and equilibrium phase scans. The fECV was calculated using the following equation: fECV (%)=E_liver× (100 - haematocrit [%])/E_aorta. Correlation between fECV and LF stage was evaluated using the Spearman correlation coefficient. The fECVs were compared between each stage of LF. The diagnostic performance of fECV was assessed using receiver operating characteristic (ROC) curve analysis.

RESULTS

The difference among the groups was statistically significant (p<0.05). The fECVs were significantly different (p<0.05) between F0 versus F4, F1 versus F4, and F2 versus F4. The fECVs showed a significant correlation with pathological LF staging (r=0.468, p=0.001). The sensitivity and specificity were 0.76 and 0.68 for severe LF (F≥3); and 0.89 and 0.63 for cirrhosis (F=4). The areas under the ROC curve (AUCs) for F≥3 and F=4 were 0.757 and 0.775, respectively.

CONCLUSIONS

Calculation of fECV during routine contrast-enhanced liver CT may provide a non-invasive means of assessing LF.

Hepatopulmonary shunting after surgical, interventional and systemic therapy in patients with liver malignancies scheduled for radioembolization

BACKGROUND

Hepatopulmonary shunts (HPS) lead to radiation exposure of the lungs in patients undergoing radioembolization (RE) of malignant liver tumors.

PURPOSE

To retrospectively analyze how HPS is affected by prior systemic or local therapy of the liver.

MATERIAL AND METHODS

The percentage HPS was calculated from SPECT/CT scans obtained after technetium-99 m macroaggregated albumin administration into hepatic arteries in 316 patients evaluated for RE.

RESULTS

Patients with partial liver resection (n = 80) did not differ in HPS from the remaining patient population (n = 236) (HPS (median [range]) = 10.2 [2.1-48.3]resection% vs. 8.9 [2.3-32.9]no resection%; P = 0.527). In patients undergoing sequential RE, HPS was significantly higher in the liver lobe treated second (n = 10; HPS = 6.4 [2.1-10.2]firstlobe/session% vs. 12.0 [2.0-24.6]second lobe/session%; P = 0.019). (Chemo-)embolization (n = 19; HPS = 11.0 [2.8-48.3]%) or transcutaneous ablation (n = 63; HPS = 8.8 [3.0-32.9]%) had no effect on HPS compared to patients without prior interventions (no (chemo-)embolization: n = 297; HPS = 9.3 [2.1-47.3]%; P = 0.489; no ablation: n = 253; HPS = 9.5 [2.1-48.3]%; P = 0.382). Pretreatment with sorafenib (HPS = 9.5 [2.3-35.9]yes% vs. 10.2 [2.8-42.0]no%; P = 0.777) orbevacizumab (HPS = 10.7 [2.1-30.6]yes% vs. 9.0 [3.9-23.3]no%; P = 0.870) had no effect on HPS.

CONCLUSION

Sequential RE results in an increase in the HPS in the contralateral liver lobe at the time of the second RE session. Other investigated therapy do not affect HPS.

Ethanol ablation in postbiopsy liver hemorrhage following two failed embolizations

A 42-year-old male presented with intraperitoneal hemorrhage 5days following percutaneous liver biopsy for suspected hepatocellular carcinoma. Diagnostic angiogram localized the bleeding to segment VI hepatic artery branches. Two consecutive arterial embolizations with microspheres and platinum coils failed to control the bleeding. The patient was a poor surgical candidate, so ultrasound-guided ethanol ablation of the bleeding source and surrounding liver segment was employed as salvage therapy. The patient stabilized clinically and was discharged home to begin palliative therapy.

Retrospective comparison of gradient recalled echo R2* and spin-echo R2 magnetic resonance analysis methods for estimating liver iron content in children and adolescents

BACKGROUND

Serial surveillance of liver iron concentration (LIC) provides guidance for chelation therapy in patients with iron overload. The diagnosis of iron overload traditionally relies on core liver biopsy, which is limited by invasiveness, sampling error, cost and general poor acceptance by pediatric patients and parents. Thus noninvasive diagnostic methods such as MRI are highly attractive for quantification of liver iron concentration.

OBJECTIVE

To compare two MRI-based methods for liver iron quantification in children.

MATERIALS AND METHODS

64 studies on 48 children and young adults (age range 4-21 years) were examined by gradient recalled echo (GRE) R2* and spin-echo R2 MRI at 1.5T to evaluate liver iron concentration. Scatter plots and Bland-Altman difference plots were generated to display and assess the relationship between the methods.

RESULTS

With the protocols used in this investigation, Bland-Altman agreement between the methods is best when LIC is <20 mg/g dry tissue. Scatter plots show that all values with LIC <20 mg/g dry tissue fall within the 95% prediction limits.

CONCLUSION

Liver iron concentration as determined by the R2* and R2 MR methods is statistically comparable, with no statistical difference between these methods for LIC <20 mg/g.