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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.

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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:

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]

Although rare, haemobilia should be considered in upper abdominal pain associated with upper gastrointestinal bleeding, especially when there is a history of liver injury or instrumentation.
  • Blood tests:
  • 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]
  • 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.
  • The mortality rate in the Southampton review discussed under 'Aetiology', above, was 5%.[2]

Further reading & 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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  11. Yoon W, Jeong YY, Kim JK, et al; CT in blunt liver trauma. Radiographics. 2005 Jan-Feb;25(1):87-104.
  12. Watanabe Y, Nagayama M, Okumura A, et al; MR imaging of acute biliary disorders. Radiographics. 2007 Mar-Apr;27(2):477-95.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Peer Reviewer:
Dr Adrian Bonsall
Document ID:
2217 (v22)
Last Checked:
Next Review:

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