Hemobilia Dr Wong Po Yan Sabrina Princess Margaret
Hemobilia Dr. Wong Po Yan, Sabrina Princess Margaret Hospital
Hemobilia… • • Case scenario Etiology Investigations Management
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
Etiology WINTER Abnormal communication between blood vessels and bile duct Percentage Template
Etiology WINTER Iatrogenic trauma Template • Percutaneous hepatic procedures › Liver biopsy › PTBD, PTC (0. 06 – 1%) (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 Haemobilia. BJS. 2001
Etiology Trauma • • WINTER Template Acute / delayed presentation (more common) Penetrating / blunt injury Grade of liver injury ≠ Degree of hemobilia Associated factors: › Cavitations ↓ Liver healing › Infection › Initial operation: packing, deep mattress sutures Hemobilia after penetrating and blunt liver injury: treatment with selective hepatic artery embolization. Injury. 2004
Etiology Quinke’s triad: WINTER Template (Slow bleeding) Blood clots Cholangitis Pancreatitis Cholecystitis Cholestasis Onset – days to weeks Haemobilia. BJS. 2001 Hemobilia: endoscopic, fluoroscopic and cholangioscopic diagnosis. Hepatology. 2010
Investigation High index of suspicion Procedure Findings OGD To exclude other sources of UGIB Ultrasound Biliary obstruction Cholecystitis Pseudoaneurysm (with Doppler) CT Pseudoaneurysm Associated injury Disease status ERCP Blood clots as filling defects Indentation by pseudoaneurysm Angiogram Contrast extravasation Pseudoaneurysm Therapeutic
Management Prevention Is the procedure really indicated? Procedure Liver biopsy Tract embolization PTBD Avoid insertion near liver hilum Cholecystectomy Avoid injury to hepatic arteries by e. g. diathermy, suture, clips Minimize infection, biloma Patient’s own risk Ascites Drainage Coagulopathy Replacement of clotting factors, vitamin K 1, withhold anti-platelet agents
Management Principle 1. Stop the bleeding 2. Drain the biliary obstruction Angiogram +/Transarterial embolization Massive hemobilia Initial management 1. Resuscitation 2. Control sepsis Predominantly obstructive ERCP
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
Management Case series No. Cause Success Failure Okasaki 1991 10 Iatrogenic 100% / Belghiti 1997 19 Iatrogenic 87% 7 underwent surgery: - 3 techinical failure - 3 hemocholecystitis - 1 ischemic cholecystitis Xu 2005 16 Mixed 75% 2 re-bleeding → 2 nd TAE 2 technical failure and died Srivastava 2006 32 Mixed 75 % 8 underwent surgery 3 re-bleeding → 2 nd TAE Tsai 2007 20 Iatrogenic 85% 3 underwent surgery: - 2 technical failure - 1 re-bleeding, failed 2 nd TAE Marynissen 2012 12 Iatrogenic 100% / 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
Management Transarterial Embolization (TAE) Post-cholecystectomy hemobilia Cystic artery stump pseudoaneurysm: Coil embolization of right hepatic artery Hemobilia after lapaporoscopic cholecystectomy. Int Surg. 2012
Management Transarterial Embolization (TAE) RPC, ERCP multiple CBD stones Quinke’s triad ERCP Readmitted for tarry stool OGD Angiogram + embolization
Management Transarterial Embolization (TAE) Metallic stents for malignant biliary obstruction All successful TAE with no re-bleeding Reports E Monroe 1993 P Mean onset Stent type 1 3 weeks Uncovered Wallstent Murayama 1997 1 1 month Uncovered Wallstent Rai 2003 1 1 year Unknown Watanabe 2012 1 9 months Uncovered Wallflex Hyun 2013 3 11 weeks Various Yasuko 2014 2 3 months Uncovered Wallflex 3 E = endoscopically placed stent P = percutaneously placed stent Pseudoaneurysm caused by self-expandable metal stents: a report of three cases. Endoscopy. 2014
Management Endoscopic management • Sphincterotomy To relieve biliary obstruction • Removal of blood clots To drain bile leak • Insertion of plastic stent • Placement of nasobiliary drain: › Irrigation › Monitoring of bleeding › Cholangiogram 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
Management Endoscopic management • 37 patients: › 28 malignancy 90% Jaundice › 8 inflammation • ERCP: › 2 Sphincterotomy only › 26 Endoscopic nasobiliary drainage › 7 Endoscopic retrograde biliary drainage • Results: › Hemobilia successfully treated in nasobiliary drainage Etiology, clinical features and endoscopic management of hemobilia: a retrospective analysis of 37 cases. Korean J Gastroenterol. 2012
Management Surgery Indications: • When TAE fails • When endoscopic or percutaneous decompression fails • Hemodynamic instability • Laparotomy for other reasons: › Cholecystitis › Resectable neoplasm
Management Surgery • • • Ligation of bleeding vessel Pseudoaneurysm excision Hepatic artery ligation (non-selective) Partial hepatic resection Exploration of CBD
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
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
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. 5 ml/min (vs. 0. 35 ml/min in angiogram) Haemobilia. BJS. 2001 Massive haemobilia: a diagnostic and therapeutic challenge. World J Surg. 2014
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
Management Transarterial Embolization (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
Management Evolution 190 3 Kehr – Ligation of right hepatic artery 197 6 Walter – Transarterial Embolization
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
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
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
Massive Hemobilia Massive haemobilia: a diagnostic and therapeutic challenge. World J Surg. 2014
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
Hemobilia after cholecystectomy
Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of literature. Eur J Gastroenterol Hepatol. 2012
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
Hemobilia after metallic stents Pseudoaneurysm caused by self-expandable metall stents: a report of three cases. Endoscopy. 2014
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