Management of a rare case of fulminant hemobilia due to arteriobiliary fistula following total pancreatectomy

Abstract

Hemobilia is a rare cause of acute upper gastrointestinal bleeding and is often associated with a history of hepatic or biliary tract injury, tumor growth, hepatic artery aneurysm, cholecystitis, or hepatic abscess. We report a case of a 76-year-old patient with massive hemobilia due to intrahepatic bleeding from the segment 8 hepatic artery without evidence of a true aneurysm, abscess, or metastatic disease 4 weeks following pylorus-preserving total pancreatectomy for pancreatic cancer. Gastroduodenoscopy suggested hemorrhage from the duodenojejunostomy but failed to achieve hemostasis, and the patient underwent exploratory laparotomy. It was realized intraoperatively that the bleeding originated from the intrahepatic biliary tract. Bleeding was controlled by blocking the right hepatic bile duct with a Fogarty catheter and subsequent transarterial embolization. Computed tomography did not reveal any local liver or vascular pathology. Retrospectively, the cause of delayed profuse hemobilia was most likely a traumatic intrahepatic pseudoaneurysm following endoscopic bile duct stenting 3 weeks before the pancreatectomy. The reported case is exceptional and of particular interest because of the absence of a typical history or cause of hemobilia, preoperative misleading diagnostic results in an altered anatomic situation, and the operative management to achieve bleeding control in this emergency setting.

Haemobilia due to hepatic artery pseudoaneurysm

“…Although this examination will not show the erosive vascular changes as seen on arteriograms, it may unveil haemorrhage or pseudoaneurysm formation 13. Interventional angiography is regarded as the ‘gold standard’ for diagnosing haemobilia and treatment of the underlying cause of bleeding 5. Transarterial embolisation (TAE) is now the first line of intervention to stop bleeding, as its reported success rate ranges from 80% to 100% 6…”

“…In these circumstances, haemobilia can be the result of a traumatic arteriobiliary fistula or a pseudoaneurysm, which accounts for 10% of haemobilia cases,4 and may present with delayed bleeding 5. Other causes of haemobilia include inflammatory disorders such as hepatic abscesses, pancreatic pseudocyst, cholangitis and cholecystitis, coagulopathy, real aneurysms and gallstone disease, as well as primary and secondary malignancies of the liver, bile duct, gallbladder and pancreas 1 6 7.…”

Hemobilia after pseudoaneurysm of a right hepatic artery branch

“…The major underlying precipitating conditions are hepatobiliary trauma, infectious diseases (colecystitis, liver abscess), neoplasms or vascular diseases (3)(4).…”

Hematoma after vacuum-assisted breast biopsy: a preventable condition?

“…Additionally, the application of an adhesive skin traction bandage for 2 to 3 days is currently adopted to limit the extent of hematoma. Independently, during surgical procedures in the hepatic bile ducts, the insertion of a Fogarty catheter into the ducts has been used as a means of controlling serious bleeding (2,3).…”