Haemobilia (bleeding in the biliary tree) occurs when conditions produce an abnormal communication between blood vessels and bile ducts.¹ It is rare and diagnosis requires a degree of diagnostic suspicion. Haemobilia may be major, causing life-threatening haemorrhage, or minor.² It can present many weeks after the initial injury.³ Bleeding can lead to biliary obstruction.

Aetiology

The most common cause is liver biopsy. Other more common causes include trauma, malignancy, arterio-biliary or arterio-portal fistula and pseudoaneurysm of the hepatic arteries.¹ Haemobilia may be due to:

• Trauma: injury may be blunt (e.g. a fall, road traffic accident) or penetrating (e.g. stab or gunshot injuries); this can lead to bleeding from an intrahepatic branch of the hepatic artery into a bile duct. A report from Cape Town included 30 patients over 36 years who had traumatic liver injury that led to haemobilia.⁴ The report stated that haemobilia occurs in fewer than 3% of liver injuries.
• Gallstones.
• Infection, e.g. liver abscess, ascariasis.
• Hepatic artery aneurysm.
• Liver tumours: these include cholangiocarcinoma, hepatocellular carcinoma.^5,6
• Iatrogenic causes: including percutaneous biliary drainage procedures, percutaneous liver biopsy, liver transplantation and operative trauma, anticoagulation. A review of 222 cases of haemobilia from Southampton found that two thirds of cases were iatrogenic and that accidental trauma accounted for only 5%.^2,7,8
• Bleeding disorders, e.g. haemophilia.⁶
• Bile duct arteriovenous malformations.^9,10
• Inflammatory conditions, e.g. polyarteritis nodosa.

There is concern that the increased use of invasive procedures and the trend toward conservative management of major trauma has resulted in an increased incidence of haemobilia. However, the Southampton review concluded that there was no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia.²

Presentation

• The classical triad is jaundice, biliary colic and upper gastrointestinal haemorrhage, often presenting as melaena or haematemesis.¹
• Bleeding may be occult and present with iron deficiency anaemia.

Investigations

• Blood tests:
  • FBC: there may be an iron deficiency anaemia with a microcytic, hypochromic picture and low ferritin if blood loss is prolonged. In the acute phase haemoglobin can be normal.
  • LFTs: cholestatic jaundice with elevated bilirubin and liver enzymes, especially alkaline phosphatase.
• Endoscopy:
  • Endoscopy is diagnostic in only 12% of cases, by visualising blood draining from the papilla of Vater.³
• Imaging:
  • CT or MRI scanning may show evidence of a clot. CT may be useful in identifying haemobilia as a complication of blunt liver trauma.¹¹
  • MRI with cholangiopancreatographic sequences and T1- and T2-weighted MRI may help to detect haemobilia.¹²
  • Diagnosis of haemobilia is usually achieved by angiography.²
  • Treatment is often possible at the same time as angiography by embolisation of the lesion.^2,4

Management

• This depends on the underlying cause.
• Assessment and management of Airway, Breathing and Circulation (ABC) should take place in the first instance.
• Conservative management may be all that is needed in minor bleeding.²
• In iatrogenic cases, conservative management is often adequate, as bleeding can stop spontaneously.
• Transcatheter hepatic artery embolisation is commonly used in the management of haemobilia.^4,5,10
• Surgical exploration may be required if embolisation fails. This can allow ligation of the bleeding point.

Prognosis

• The mortality rate in the Southampton review discussed under 'Aetiology', above, was 5%.²

Document references

1. Demyttenaere SV, Hassanain M, Halwani Y, et al; Massive hemobilia. Can J Surg. 2009 Aug;52(4):E109-E110.
2. Green MH, Duell RM, Johnson CD, et al; Haemobilia. Br J Surg. 2001 Jun;88(6):773-86. [abstract]
3. Bruens ML, De Smet A, Vroegindeweij D, et al; Haemobilia 2 weeks after a low thoracic stab wound. HPB (Oxford). 2005;7(4):318-9. [abstract]
4. Forlee MV, Krige JE, Welman CJ, et al; Haemobilia after penetrating and blunt liver injury: treatment with selective hepatic artery embolisation. Injury. 2004 Jan;35(1):23-8. [abstract]
5. Takao Y, Yoshida H, Mamada Y, et al; Transcatheter hepatic arterial embolization followed by microwave ablation for hemobilia from hepatocellular carcinoma. J Nippon Med Sch. 2008 Oct;75(5):284-8. [abstract]
6. Manolakis AC, Kapsoritakis AN, Tsikouras AD, et al; Hemobilia as the initial manifestation of cholangiocarcinoma in a hemophilia B patient. World J Gastroenterol. 2008 Jul 14;14(26):4241-4. [abstract]
7. Edden Y, St Hilaire H, Benkov K, et al; Percutaneous liver biopsy complicated by hemobilia-associated acute cholecystitis. World J Gastroenterol. 2006 Jul 21;12(27):4435-6. [abstract]
8. Wojcicki M, Milkiewicz P, Silva M; Biliary tract complications after liver transplantation: a review. Dig Surg. 2008;25(4):245-57. Epub 2008 Jul 15. [abstract]
9. Hayashi S, Baba Y, Ueno K, et al; Small arteriovenous malformation of the common bile duct causing hemobilia in a patient with hereditary hemorrhagic telangiectasia. Cardiovasc Intervent Radiol. 2008 Jul;31 Suppl 2:S131-4. [abstract]
10. Srivastava DN, Sharma S, Pal S, et al; Transcatheter arterial embolization in the management of hemobilia. Abdom Imaging. 2006 Jul-Aug;31(4):439-48. [abstract]
11. Yoon W, Jeong YY, Kim JK, et al; CT in blunt liver trauma. Radiographics. 2005 Jan-Feb;25(1):87-104. [abstract]
12. Watanabe Y, Nagayama M, Okumura A, et al; MR imaging of acute biliary disorders. Radiographics. 2007 Mar-Apr;27(2):477-95. [abstract]