Hamad Ahmad, MD1, Urooj Khan, MD2, Hoore Jannat, MD3, Noaman Ahmad, MD4 1Westchester Medical Center, White Plains, NY; 2Khyber Medical University, Huntsville, AL; 3Khyber Medical College, White Plains, NY; 4Huntsville Hospital, Huntsville, AL
Introduction: Hemobilia, an uncommon cause of upper gastrointestinal bleeding (UGIB), occurs when there is bleeding from the liver or biliary tract. Patients who experience acute UGIB with a recent history of hepatobiliary trauma or procedures, such as liver biopsy, percutaneous transhepatic cholangiogram, bile duct biopsies or stenting, or TIPS placement, should be assessed for the possibility of hemobilia. Diagnostic procedures like endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) should be considered to evaluate the presence of hemobilia.
Case Description/Methods: A 62-year-old male with a history of Roux-en-Y gastric bypass (RYGB) and hypertension presented with worsening right upper quadrant (RUQ) pain and vomiting. An RUQ ultrasound showed sludge in the gallbladder, dilated intrahepatic and extrahepatic biliary ducts, and a 2-cm stone in the common bile duct (CBD). An MRCP confirmed a stone in the distal CBD, causing dilation of the CBD and intrahepatic ducts. Due to complicated anatomy post-RYGB, the patient could not have ERCP and hence underwent percutaneous transhepatic biliary drainage and CBD stone extraction. The hospital stay was complicated by atrial fibrillation (Afib), requiring cardioversion, and the patient was started on anticoagulation for stroke prevention. The next day, the patient experienced a significant drop in hemoglobin levels with black stools, suggesting UGIB. Anticoagulation was discontinued. The patient underwent an esophagogastroduodenoscopy (EGD), colonoscopy, and pill camera study, which did not identify the source of bleeding. Due to persistent melena and decreasing hemoglobin levels, hemobilia was suspected. As the patient could not get an ERCP, it was decided to do a laparoscopic cholecystectomy for suspected hemobilia. Post-cholecystectomy, the patient's melena resolved completely, and hemoglobin levels remained stable.
Discussion: The traditional triad of hemobilia consists of biliary colic, obstructive jaundice, and acute UGIB. Although hemobilia is not a common condition, it is important to have a low threshold of suspicion in the context of recent hepatobiliary procedures, as in our patient's case. Treatment typically focuses on addressing the underlying cause of the bleeding. However, laparoscopic cholecystectomy may be considered and has proven very effective for suspected cases of hemobilia in patients who have otherwise undergone negative investigations for upper gastrointestinal bleeding.
Figure: Figure 1: Cholangiogram shows distal CBD stone; Figure 2: Post CBD stone extraction cholangiogram with drain placed; EGD: Normal mucosa with no ulceration, AV malformation or inflammation
Disclosures:
Hamad Ahmad indicated no relevant financial relationships.
Urooj Khan indicated no relevant financial relationships.
Hoore Jannat indicated no relevant financial relationships.
Noaman Ahmad indicated no relevant financial relationships.
Hamad Ahmad, MD1, Urooj Khan, MD2, Hoore Jannat, MD3, Noaman Ahmad, MD4. P2950 - Hemobilia: An Uncommon Presentation of Upper Gastrointestinal Bleeding, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.