Hemobilia

1. Dr. Wong Po Yan, Sabrina Princess Margaret Hospital Hemobilia

2. Hemobilia… • Case scenario • Etiology • Investigations • Management

3. 49 year old lady • Past health: chronic rheumatic heart disease on warfarin • Admitted for epigastric pain • CT • ERCP • Repeat CT • Angiogram • Repeat ERCP Cholangiocarcinoma Hilar mass Hemobilia

4. Etiology WINTER Abnormal communication between blood vessels and bile duct Template Percentage

5. Etiology WINTER • Iatrogenic trauma • Percutaneous hepatic procedures • Liver biopsy (0.06 – 1%) • PTBD, PTC (2 – 10%) • Cholecystectomy • Hepatic artery pseudoaneurysm • Cystic artery stump pseudoaneurysm • Instrumentation • Metallic stents (0.5% endoscopic, 1.6% percutaneous) • Plastic stents • Other case reports: T-tube, RFA, lithotripsy, ECBD Template Haemobilia. BJS. 2001

6. Etiology WINTER • Trauma • Acute / delayed presentation (more common) • Penetrating / blunt injury • Grade of liver injury ≠ Degree of hemobilia • Associated factors: • Cavitations • Infection • Initial operation: packing, deep mattress sutures Template ↓ Liver healing Hemobilia after penetrating and blunt liver injury: treatment with selective hepatic artery embolization. Injury. 2004

7. Etiology WINTER Template Quinke’s triad: (Slow bleeding) Blood clots Cholangitis Pancreatitis Cholecystitis Cholestasis Onset – days to weeks Haemobilia. BJS. 2001 Hemobilia: endoscopic, fluoroscopic and cholangioscopic diagnosis. Hepatology . 2010

8. Investigation High index of suspicion Therapeutic

9. Management Prevention  Is the procedure really indicated?

10. Management Principle Stop the bleeding Drain the biliary obstruction Angiogram +/- Transarterial embolization ERCP Initial management Resuscitation Control sepsis

11. Management • Transarterial Embolization (TAE) • Diagnostic rate >90% • Success rate 80 – 100% • Pre-requisite: • Patent portal vein • Patent hepatic artery • Celiac axis angiogram • Superior mesenteric angiogram • Selective embolization

12. Management Angiographic management of massive hemobilia due to iatrogenic trauma. Gastrointestinal Radiology. 1991 Selective surgical indications in iatrogenic hemobilia. Surgery. 1997 Evaluation of selective hepatic angiography and embolization in patients with massive hemobilia. Hepatobiliary and Pancreatic Dis Int. 2005 Transcatheter embolization in management of hemobilia. Abdom Imaging. 2006 Transcatheter arterial coil embolization of iatrogenic pseudoaneurysms after hepatobiliary and pancreatic interventions. Hepatogastroenterology. 2007 Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of literature. Eur J Gastroenterol Hepatol. 2012

13. Management Transarterial Embolization (TAE) Post-cholecystectomy hemobilia Cystic artery stump pseudoaneurysm: Coil embolization of right hepatic artery Hemobilia after lapaporoscopic cholecystectomy. Int Surg. 2012

14. Management Transarterial Embolization (TAE) RPC, ERCP multiple CBD stones Quinke’s triad ERCP Readmitted for tarry stool OGD Angiogram + embolization

15. Management Transarterial Embolization (TAE) Metallic stents for malignant biliary obstruction All successful TAE with no re-bleeding E = endoscopically placed stent P = percutaneously placed stent Pseudoaneurysm caused by self-expandable metal stents: a report of three cases. Endoscopy. 2014

16. Management • Endoscopic management • Sphincterotomy • Removal of blood clots • Insertion of plastic stent • Placement of nasobiliary drain: • Irrigation • Monitoring of bleeding • Cholangiogram To relieve biliary obstruction To drain bile leak Endoscopic management of traumatic hemobilia. Journal of Trauma. 2007 Etiology, clinical features and endoscopic management of hemobilia: a retrospective analysis of 37 cases. Korean J Gastroenterol. 2012

17. Management • Endoscopic management • 37 patients: • 28 malignancy • 8 inflammation • ERCP: • 2 Sphincterotomy only • 26 Endoscopic nasobiliary drainage • 7 Endoscopic retrograde biliary drainage • Results: • Hemobilia successfully treated in nasobiliary drainage 90% Jaundice Etiology, clinical features and endoscopic management of hemobilia: a retrospective analysis of 37 cases. Korean J Gastroenterol. 2012

18. Management • Surgery • Indications: • When TAE fails • When endoscopic or percutaneous decompression fails • Hemodynamic instability • Laparotomy for other reasons: • Cholecystitis • Resectable neoplasm

19. Management • Surgery • Ligation of bleeding vessel • Pseudoaneurysm excision • Hepatic artery ligation (non-selective) • Partial hepatic resection • Exploration of CBD

20. Conclusion • Iatrogenic trauma is the most common cause • Diagnosis requires high index of suspicion • Transarterial embolization in massive hemobilia • Endoscopic biliary decompression is important • Surgery is the last resort

22. Management • Other development • USG guided percutaneous thrombin injection for pseudoaneurysm Cystic artery pseudoaneurysm presenting as a complication of laparoscopic cholecystectomy treated with percutaneous thrombin injection. Clinical Imaging. 2014

23. Investigation • Ultrasound • Hyper-echoic blood may be confused as stones • Iso-echoic clot, the bile ducts may not be visualized • Sensitivity varies widely 40 – 90% • CTA • Detect hemorrhage 0.5ml/min (vs. 0.35ml/min in angiogram) Haemobilia. BJS. 2001 Massive haemobilia: a diagnostic and therapeutic challenge. World J Surg. 2014

24. Investigation Bleeding from PTBD – Tractogram / Cholangiogram Absent central bile duct sign Transgression of portal vein Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Techniques in vascular and interventional radiology. 2008

25. Management • TransarterialEmbolization (TAE) • Low morbidity • Post-embolization syndrome • Hepatic necrosis • Liver abscess • Re-bleeding • Non-target embolization • Ischemic cholecystitis, pancreatitis • Catheter-induced damage of arteries • Access site morbidity • Contrast morbidity Transcatheter arterial embolization in the management of hemobilia. Abd Imaging. 2006

26. Management Evolution

27. Management Transarterial Embolization (TAE) Previous PTBD for CA pancreas (3 weeks after Whipple operation): Coil embolization of branch of right hepatic artery Hepatobiliary and pancreatic: iatrogenic hemobilia. J Gastroenterol Hepatol. 2008

28. Management Transarterial Embolization (TAE) Bleeding from PTBD SMA Celiac axis Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Techniques in vascular and interventional radiology. 2008

29. Hemobilia from PTBD Yes Is patient stable? No Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Techniques in vascular and interventional radiology. 2008

30. Massive Hemobilia Massive haemobilia: a diagnostic and therapeutic challenge. World J Surg. 2014

31. Tract embolization in liver biopsy • Indications: • Coagulopathy: INR> 1.5, platelet <20000, von Willebrand disease • Active oozing from needle tract • Chronic renal failure • Hypertension (SBP >160, DBP > 100, MBP > 120) • Embolizing agents: • gelfoam, coils, N-butyl cyanoacrylate • Technique: • Use introducer in biopsies (co-axial system) • Exchange catheter with vascular sheath in drainage procedure Techniques in intervention radiology. 2010 Ultrasound-guided plugged percutaneous biopsy of solid organs in patients with bleeding tendencies. HKMJ. 2014

32. Hemobilia after cholecystectomy

33. Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of literature. Eur J Gastroenterol Hepatol. 2012

34. Hemobilia after metallic stents • Risk factors: chemotherapy, irradiation • Mechanism for pseudoaneurysm formation: • Direct trauma to nearby vessels • Chronic inflammation & fibrosis • Pressure exerted onto tumor Wallstent vs. Wallflex Pseudoaneurysm caused by self-expandable metall stents: a report of three cases. Endoscopy. 2014

35. Hemobilia after metallic stents Pseudoaneurysm caused by self-expandable metall stents: a report of three cases. Endoscopy. 2014