Hemobilia: A cause of false‐negative ductal dilatation

Abstract

Ultrasound is a well-established method of evaluating bile duct size, with accuracy rates ranging from 86 to 93%' Reasons for false-negative interpretation in cases of obstructive jaundice include lack of ductal dilatation in the presence of a common duct stone, sclerosing cholangitis, tumor encasement of the ducts (either from metastatic or cholangiocarcinoma), ducts filled with "debris," and technical difficulties often related to prior surgery in the area.'-4 This case report illustrates another cause of false-negative interpretation that is becoming increasingly important as the use of interventional procedures increases, namely, hemobilia in which clot fills a large portion of the ductal system and obscures its normally bile-filled lumen. CASE REPORTA 73-year-old black male presented with right upper quadrant pain, fever, and weakness. He was clinically icteric, and admission laboratory studies showed a total bilirubin level of 9.2 mg and alkaline phosphatase greater than 350 mg Ulliter. His history included surgery 46 years ago for adenocarcinoma of the stomach, with a recurrence at the stump 2 years prior to admission requiring a total gastrectomy. Cholecystectomy was performed 12 years previously for an uncomplicated cholecystitis. A common duct stone was diagnosed the year prior to this admission. The stone was partially dissolved chemically with monooctanoin and removed percutaneously.On this admission, the initial ultrasound examination showed a distal common duct measur-

Hemobilia

“…Later, after contraction, the clot conforms to the tubular structure of the duct and may be mistaken for the true lumen. These potential problems limit the diagnostic utility of ultrasound [59,60]. Less specific findings are usually seen on ultrasound in patients with hemobilia including cholelithiasis, a dilated biliary tree, evidence of liver contusion, hepatic tumor, or pseudoaneurysm identified as anechoic mass with flow on color Doppler.…”

Hemobilia: Diagnosis and Management

“…Side view duodenoscope is useful in making the diagnosis of hemobilia. The yield of endoscopy is dependent on rate and duration of bleeding, all hemobilia patients had lower positive endoscopic findings 12.0-37.5% 8,34 but in clinical significant hemobilia suggested that the yield was close to 100.0% 32 and further investigation should be undertaken ( Figure 2).…”

“…These finding is limitation to diagnosis hemobilia. 34,35 Ultrasound is useful in diagnosis of underlying disease; cholelithiasis, biliary ascariasis, liver mass and pseudoaneurysm of hepatic artery (Doppler ultrasound).…”