Haemobilia

What is haemobilia?

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

Haemorrhage into the biliary tree is predominantly arterial in origin due to the high-pressure differential between the hepatic artery and bile ducts.⁴

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 (eg a fall, road traffic accident) or penetrating (eg 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.⁵ The report stated that haemobilia occurs in fewer than 3% of liver injuries.

• Gallstones.

• Infection, eg, liver abscess, ascariasis.

• Hepatic artery aneurysm.

• Liver tumours: these include cholangiocarcinoma, hepatocellular carcinoma.^{6 7}

• 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 8 9}

• Bleeding disorders, eg, haemophilia.⁷

• Bile duct arteriovenous malformations.^{10 11}

• Inflammatory conditions, eg, polyarteritis nodosa.

• Cholecystitis (very rarely).¹²

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

Haemobilia symptoms (presentation)⁴

• Presenting symptoms include melaena, abdominal pain, haematemesis, and jaundice. Slowly bleeding lesions may present as iron-deficiency anaemia.

• The clinical triad of jaundice, upper abdominal pain, and obscure upper GI bleeding suggests a biliary tract bleeding source. However, only 22-35% of patients will have all these three symptoms.

• In patients with a percutaneous transhepatic biliary drain in place, bloody output from the biliary drain or along biliary drain tract may be the first sign of haemobilia.

• The onset of bleeding after an interventional procedure or trauma is variable, ranging from a few days to months. Most commonly, haemobilia occurs within 4 weeks of bile duct injury. Iatrogenic endoscopic retrograde cholangiopancreatography (ERCP)-related haemobilia tends to occur immediately after or within several days of the procedure. Delayed onset can be due to bile stasis, hepatic necrosis, or a slowly expanding pseudoaneurysm.

• Chronic bile duct erosion and inflammation can also result in injury to adjacent vessels and delayed-onset haemobilia.

Haemobilia is frequently accompanied by clot formation within the biliary system. Clot formation may result in biliary obstruction and jaundice.

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.¹³

  • MRI with cholangiopancreatographic sequences and T1- and T2-weighted MRI may help to detect haemobilia.¹⁴

  • 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 5}

Haemobilia treatment and management¹⁵

• 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.

• In iatrogenic cases, conservative management is often adequate, as bleeding can stop spontaneously.

• Interventional angiography remains the first treatment option of haemobilia. Selective arterial ligation or hepatectomy remain the options in case of lack of angiography or insufficient results after embolisation.

Prognosis

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