Hemobilia: Perspective and Role of the Advanced Endoscopist

Abstract

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon cause of gastrointestinal hemorrhage. Hemobilia has been documented since the 1600s, but due to its relative rarity, it has only been more critically examined in recent decades. Most cases of hemobilia are iatrogenic and caused by procedures involving the liver, pancreas, bile ducts, and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other major causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described, but this is present in only 25–30% of patients with hemobilia. Historically, the gold standard for diagnosis and treatment has been angiography and interventional radiologic intervention, respectively. However, the paradigm is shifting, at least in select cases, towards first-line reliance on noninvasive imaging (e.g., computed tomography) and therapeutic endoscopy, owing to advances in and the less invasive nature of both, while saving interventional radiological and/or surgical intervention for refractory or imminently life-threatening cases.

Massive hemobilia caused by rupture of gastroduodenal artery pseudoaneurysm, a delayed complication of laparoscopic cholecystectomy: a case report

“…In this case report, we present a patient with characteristics concordant with the Quincke’s triad [ 4 ]. Hemobilia is a rare etiology of UGIB and often missed in the early diagnosis establishment, especially when there is no history of trauma or invasive hepatopancreatobiliary procedure [ 1 ].…”

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhag

“…12 Depending on the source, however, interventional radiology consultation for embolization of a bleeding vessel demonstrating extravasation may also be considered. 13,14 Postoperatively, these patients may also be at high risk for biliary complications, including leak, given the ischemic burden on the biliary system during hemorrhage and shock requiring resuscitation. In these instances, ERCP remains the gold standard for management.…”

Cholecystitis and hemobilia

“…2). The classic presentation of hemobilia is described by Quinke’s triad: right upper quadrant pain, jaundice and gastrointestinal bleeding, with all three present in only 25–33% of cases [4].…”

“…When blood is seen coming from the ampulla, concern for hemobilia arises [6]. A recent publication from the University of California illustrates the role of the advanced endoscopist as an alternate first-line therapy for hemobilia when found on EGD or ERCP, using described hemostatic techniques such as epinephrine injection, mono- or bi-polar coagulation, fibrin sealants, hemoclips or others [4].…”