Haemobilia

Haemobilia is bleeding in the biliary tree. It is not obvious like haematuria or haemoptysis but requires a degree of diagnostic suspicion.

Haemobilia is rare. Much of the literature describes isolated case reports.

• Trauma: Blunt Trauma as after a fall or RTA or penetrating trauma such as a stab or gunshot injuries.
• Gall stones in the bile duct.
• Infection: Infectious cholangitis or hepatic abscess. Infestations with Ascaris lumbricoides and cholangiohepatitis are possible causes in the Far East.
• Aneurysm (true or false) of the hepatic artery.
• Liver Tumours eg cholangiocarcinoma and hepatocellular carcinoma.
• Iatrogenic causes: percutaneous biliary drainage procedures ?endoprosthesis placement (commonest cause),¹ percutaneous liver biopsy, percutaneous transhepatic cholangiography (PTC), hepatic artery chemoembolisation, operative trauma and anticoagulation.

A report from Cape Town² found 30 patients over 36 years. Only 10 of those cases were due to trauma of which 8 were penetrating trauma and 2 blunt trauma. They said that haemobilia occurs in less than 3% of liver injuries. The mean delay between the initial injury and the diagnosis of haemobilia was 23.5 days (range 1 to 120). A review from Southampton³ found that two thirds of cases were iatrogenic and that accidental trauma accounted for only 5%. Percutaneous biliary drainage is the commonest cause of haemobilia.¹

The classical triad is:

• Cholestatic jaundice.
• Biliary colic (see right upper quadrant pain.)
• Upper GI haemorrhage, often presenting as melena.

Bleeding may be gross or occult. If gross there may be haematemesis and/or melaena. If occult there may be iron deficiency ± anaemia. Bleeding may be profuse in traumatic cases with an average of 8 units of blood (range 3 to 19) being required before angiography.

Although haemobilia is rare it should be considered in the differential diagnosis of obscure gastro-intestinal bleeding, particularly when accompanied by colic and jaundice.⁴

There may be an iron deficiency anaemia with a microcytic, hypochromic picture and low ferritin if blood loss is prolonged but in the acute phase there may have been no time for haemodilution so that Hb is normal. Cholestatic jaundice gives abnormal LFTs with elevated bilirubin and liver enzymes, especially alkaline phosphatase.

Endoscopy may reveal blood coming from the biliary duct and this is often the first indication that there is haemobilia.⁵ CT or MRI may show evidence of clot. CT is superior to ultrasonography and is very useful in blunt liver trauma.⁶ MRI imaging with cholangiopancreatographic sequences plays a critical role in evaluating alterations in the biliary tract after surgical procedures such as cholecystectomy, liver transplantation, hepatic resection, and the creation of a biliary-enteric anastomosis.⁷

The "gold standard" diagnostic procedure is arteriography of the hepatic artery. Treatment is often possible at the same time by embolisation of the lesion.^2,3,5 This should be attempted as often it will make laparotomy unnecessary.

Management of upper GI bleeding is becoming more in the province of the radiologist than the surgeon.⁸ If there is significant exsanguination, haemodynamic stability must be assured with blood transfusion if necessary. In iatrogenic cases, conservative management is often adequate as bleeding stops spontaneously. If the underlying cause is malignant, definitive management is much more difficult as curative surgery is uncommon in cholangiocarcinoma and hepatocellular carcinoma. Embolisation has used stainless steel balls, gelfoam and analogous clot. Biliary colic will require relief of pain. Pethidine is preferable to morphine or diamorphine as they can cause spasm of the sphincter of Oddi.

Surgery

Surgical exploration may be required. Any tear to the liver must be repaired and vessels either repaired or ligated. Either direct ligation of the bleeding vessel or ligation of a proximal branch of the hepatic artery is required.

The review from Southampton³ searched the English language literature and found 222 cases worldwide. Management was aimed at stopping bleeding and relieving biliary obstruction. In 43% of cases management was conservative and 36% were managed by transarterial embolisation (TAE). Surgery was indicated when laparotomy was performed for other reasons and for failed TAE. The mortality rate was 5%. They concluded that the incidence of iatrogenic haemobilia has risen considerably but the bleeding is often minor and can be managed conservatively. When more urgent intervention is required, TAE is usually the treatment of choice. There is no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia.