Haemobilia due to iatrogenic portobiliary fistula after cholecystectomy

Abstract

SUMMARYHaemobilia, defined as bleeding into the biliary tree is a rare condition. We describe a case report of a patient who presented it as a complication of iatrogenic portobiliary fistula, followed after an open cholecystectomy. The patient presented to the emergency department with late onset symptoms of haematemesis and melena a month after surgery. Findings were confirmed by Doppler ultrasound that showed the appearance of intragallbladder mass with high echogenicity representing a blood clot. Also, next to the portal vein and the biliary duct a lesion with mixed blood flow was detected confirming a portobiliary fistula. This case was successfully managed by angiography and selective embolisation. BACKGROUND

Porto-biliary fistula as an uncommon cause of haemobilia: A case report and literature review

“…The most common causes related to haemobilia are iatrogenic injuries (65 %) after percutaneous liver biopsy, following laparoscopic cholecystectomy, associated with percutaneous biliary drainage placement, following ERCP, or after transjugular portosystemic shunt placement (TIPS), followed by accidental trauma (15 %) and inflammatory diseases (9 %) [6] , [10] . These procedures could generate an increased inflammatory response near to the vessels (with the formation of small pseudoaneurysms in some cases) and due to bile fluid contact an endothelium injury [1] , [4] , [11] . Rare cases have been related to chronic obstruction of the bile ducts [12] .…”

“…It refers to the extravasation of blood through the bile duct [2] . Haemobilia is evidenced in liver trauma (55 %), inflammatory diseases (28 %), vascular malformations (11 %), bile duct tumors, and, in less proportion, periampullary tumors (6 %) [3] , [4] . However, its rate has increased with minimally invasive procedures performance and pancreatic localized procedures [5] .…”

Hemobilia after laparoscopic gallbladder bed resection and portal lymphadenectomy for incidental gallbladder adenocarcinoma

“…Quincke's triad should be an alert to hemobilia. Usually, there is a two week asymptomatic period before the bleeding starts, but it can be as long as one year [11]. Bleeding may be constant or intermittent; it can be slow and manifest as blood clots in the biliary ducts and melena, or it can be fast and cause hemodynamic instability and hematochezia [3].…”

“…When blood clots obstruct the bile ducts, jaundice and pain worsens. Otherwise, pain usually alleviates after blood loss [11].…”

Portobiliary fistula following laparoscopic cholecystectomy

“…Of the first two, one occurred after open cholecystectomy; it was discovered postoperatively by angiography and managed successfully with selective embolisation. 4 The other case was only discovered after the patient subsequently underwent an ERCP. It was managed conservatively with resolution noted on repeat imaging.…”