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Radiology
Haemobilia
Complicating ERCP Assisted Billiary Stenting: Successful Endovascular Treatment
A 44-year-old man had initially presented with pain in the right hypochondrium and yellow discolouration of eyes of one-month's duration. He had been diagnosed as an inoperable case of carcinoma of the head of the pancreas (FNAC- Adenocarcinoma) with obstructive jaundice. Subsequently, ERCP guided Teflon stents (8F) were deployed to drain the obstructed right and left biliary systems. Three weeks following stent deployment, the patient presented with signs and symptoms of cholangitis due to inadequate decompression of right billiary system as evident by moderate dilatation of the right-sided IHBR. Therefore, ERCP assisted replacement of the stent of right billiary system was done using a 10 F stent. Following this replacement, the patient's general condition gradually deteriorated. He developed malena with rapid fall in hemoglobin (11.5 gm % to 5.6 gm %) over a period of one week.
UGI scopy demonstrated a steady ooze of blood-tinged bile from duodenal papilla. Sonography revealed mild to moderate dilatation of IHBR more on the right with a well-defined anechoic lesion in the right lobe of liver with turbulent flow within, on colour Doppler (Fig.1). CT scan demonstrated a hypodense lesion, with surrounding focal dilatation of IHBR in right lobe of liver with enhancement in arterial phase on post contrast CT (Fig.2A &B). Celiac angiography revealed no abnormality (Fig 3). Superior mesenteric angiography showed a replaced right hepatic artery and a pseudoaneurysm of an intrahepatic branch of the right hepatic artery (Fig .4). A 5F cobra catheter was replaced with Jet stream catheter (0.038,150 cms)(Mallinckrodt) over the exchange wire (0.035, 260cms) (Terumo). The jet stream catheter was navigated up to the neck of the pseudoaneurysm using road map and selective angiogram which revealed active extravasation of the contrast into the biliary radicals (Fig .5)
The pseudoanerysm of branch of the replaced right hepatic artery was embolised by deployment of two coils i.e. one 3x120 mm spiral peripheral tungsten coil (BALT) within the aneurysm and other 3mmx5cm fibered steel coil (Cook INC.) across the neck and proximal to the aneurysm. The check angiogram confirmed complete exclusion of the pseudoaneurysm from circulation (Fig 6A & B).
Post procedure endoscopy confirmed complete resolution of haemobilia. The malena subsided over the next two days. The haemoblobin level of the patient gradually increased from 5.6gm% to 13.3 gm% over one week and there was significant improvement in general well being of the patient.
DISCUSSION:
Haemobilia i.e. haemorrage into the biliary tree usually results from intrahepatic vessel disruption, with acccumulation of blood within the liver parenchyma usually in the form of pseudoaneurysm; which then ruptures in the low pressure biliary system thereby forming an arteriobiliary or venobiliary fistula.
Although trauma was supposed to be the most common cause of haemobilia (50%), diagnostic and therapeutic hepatobiliary procedures have replaced trauma as the most common cause. Iatrogenic causes like diagnostic biopsy, percutaneous cholangiography, biliary drainage procedures, endobiliary prosthesis placement may cause haemobilia. Hepatobiliary surgery is another cause of iatrogenic haemobilia. Arteriobiliary fistula can occur due to trauma or may be a result of spontaneous rupture of haematomas, necrotic liver tissue, abscesses or aneurysms into the bile ducts. Venobiliary fistulae can occur between the hepatic or portal veins and the biliary radicles. Intraparenchymal bile and abscess predispose to hemobilia as they retard the healing process and cause lysis of any blood clot. Rupture of large veins along the biliary radicles or gall bladder in portal hypertension is yet another cause of haemobilia.
Although presentation with GI bleed as haematemesis or malena, jaundice and biliary colic is the classical presentation of haemobilia, it is usually present in only 1/3 rd of the patients. Additional features like palpable mass in the abdomen, dull aching abdominal pain, fever may also be associated. The presence of anemia is another important sign. Direct observation of blood coming out of the papilla is the only definitive diagnostic sign of haemobilia, which however may be false negative in 50% cases due to the intermittent nature of the disease, where extended endoscopic observation of the papilla is indicated.
It needs a high degree of suspicion to diagnose haemobilia even with the newer imaging modalities. . Abdominal ultrasound is a goood screening modality which may show a hypoechoic mass lesion suggestive of haematoma or an anechoic lesion with active flow within on colour Doppler suggestive of a pseudoaneurysm. An echogenic collection in GB on USG or presence of blood clots in GB on CT scan highly suggests haemobilia. Percutaneous cholangiography or ERCP may reveal filling defects in the biliary system suggestive of clots, although it is not pathognomonic of haemobilia. Coeliomesenteric angiography is the most rewarding investigation where the commonest finding is the presence of a pseudoaneurysm. Direct extavasation of contrast into the biliary system revealing the arteriobiliary fistula is diagnostic but seen in 25% cases only. An important advantage of this investigation is that it helps to decide the plan of management of haemobilia usually in the same sitting.
Conservative management of haemobilia is associated with high mortality as spontaneous thrombosis of the pseudoaneurysms is rarely noted. So prompt and active management is recommended in the form of surgical or transcatheter endovascular intervention .The surgical treatment includes liver suturing or partial hepatic resection for peripheal lesion and hepatic artery ligation for more central lesion and choecystectomy where the GB is the site of bleeding. However, the surgical morbidity and motrtality can be significantly reduced with transcatheter approach. Angiographic embolisation is aimed at excluding he vascular lesion out of the circulation to avoid filling of the lesion by subsequent collateral formation all the potential feeders of the vascular lesion are embolised e.g. in case of a hepatic artery pseudoaneurysm it is mandatory embolise distal as well as proximal part of the artery bearing the pseudoaneurysm. The embolisation material used may be permanant embolising agent e.g.coils or polyvinyl alcohol (PVA) particles or temporary embolising agents e.g. Gelfoam. Transcatheter embolisation using permanent or temporary embolising agents has become the treatment of choice for control of hemobilia.
In summary, under experienced hands, angiographic control of bleeding as haemobilia has been established as the standard of care with lowest complications.
Case 17 : Contributed
by Dr. Suyash Kulkarni
Other Cases
A 44-year-old man had initially presented with pain in the right hypochondrium and yellow discolouration of eyes of one-month's duration. He had been diagnosed as an inoperable case of carcinoma of the head of the pancreas (FNAC- Adenocarcinoma) with obstructive jaundice. Subsequently, ERCP guided Teflon stents (8F) were deployed to drain the obstructed right and left biliary systems. Three weeks following stent deployment, the patient presented with signs and symptoms of cholangitis due to inadequate decompression of right billiary system as evident by moderate dilatation of the right-sided IHBR. Therefore, ERCP assisted replacement of the stent of right billiary system was done using a 10 F stent. Following this replacement, the patient's general condition gradually deteriorated. He developed malena with rapid fall in hemoglobin (11.5 gm % to 5.6 gm %) over a period of one week.
UGI scopy demonstrated a steady ooze of blood-tinged bile from duodenal papilla. Sonography revealed mild to moderate dilatation of IHBR more on the right with a well-defined anechoic lesion in the right lobe of liver with turbulent flow within, on colour Doppler (Fig.1). CT scan demonstrated a hypodense lesion, with surrounding focal dilatation of IHBR in right lobe of liver with enhancement in arterial phase on post contrast CT (Fig.2A &B). Celiac angiography revealed no abnormality (Fig 3). Superior mesenteric angiography showed a replaced right hepatic artery and a pseudoaneurysm of an intrahepatic branch of the right hepatic artery (Fig .4). A 5F cobra catheter was replaced with Jet stream catheter (0.038,150 cms)(Mallinckrodt) over the exchange wire (0.035, 260cms) (Terumo). The jet stream catheter was navigated up to the neck of the pseudoaneurysm using road map and selective angiogram which revealed active extravasation of the contrast into the biliary radicals (Fig .5)
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Fig.1
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Fig.2A
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Fig.2B
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Fig.3
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Fig.4
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Fig.5
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The pseudoanerysm of branch of the replaced right hepatic artery was embolised by deployment of two coils i.e. one 3x120 mm spiral peripheral tungsten coil (BALT) within the aneurysm and other 3mmx5cm fibered steel coil (Cook INC.) across the neck and proximal to the aneurysm. The check angiogram confirmed complete exclusion of the pseudoaneurysm from circulation (Fig 6A & B).
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Fig.6A
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Fig.6B
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Post procedure endoscopy confirmed complete resolution of haemobilia. The malena subsided over the next two days. The haemoblobin level of the patient gradually increased from 5.6gm% to 13.3 gm% over one week and there was significant improvement in general well being of the patient.
DISCUSSION:
Haemobilia i.e. haemorrage into the biliary tree usually results from intrahepatic vessel disruption, with acccumulation of blood within the liver parenchyma usually in the form of pseudoaneurysm; which then ruptures in the low pressure biliary system thereby forming an arteriobiliary or venobiliary fistula.
Although trauma was supposed to be the most common cause of haemobilia (50%), diagnostic and therapeutic hepatobiliary procedures have replaced trauma as the most common cause. Iatrogenic causes like diagnostic biopsy, percutaneous cholangiography, biliary drainage procedures, endobiliary prosthesis placement may cause haemobilia. Hepatobiliary surgery is another cause of iatrogenic haemobilia. Arteriobiliary fistula can occur due to trauma or may be a result of spontaneous rupture of haematomas, necrotic liver tissue, abscesses or aneurysms into the bile ducts. Venobiliary fistulae can occur between the hepatic or portal veins and the biliary radicles. Intraparenchymal bile and abscess predispose to hemobilia as they retard the healing process and cause lysis of any blood clot. Rupture of large veins along the biliary radicles or gall bladder in portal hypertension is yet another cause of haemobilia.
Although presentation with GI bleed as haematemesis or malena, jaundice and biliary colic is the classical presentation of haemobilia, it is usually present in only 1/3 rd of the patients. Additional features like palpable mass in the abdomen, dull aching abdominal pain, fever may also be associated. The presence of anemia is another important sign. Direct observation of blood coming out of the papilla is the only definitive diagnostic sign of haemobilia, which however may be false negative in 50% cases due to the intermittent nature of the disease, where extended endoscopic observation of the papilla is indicated.
It needs a high degree of suspicion to diagnose haemobilia even with the newer imaging modalities. . Abdominal ultrasound is a goood screening modality which may show a hypoechoic mass lesion suggestive of haematoma or an anechoic lesion with active flow within on colour Doppler suggestive of a pseudoaneurysm. An echogenic collection in GB on USG or presence of blood clots in GB on CT scan highly suggests haemobilia. Percutaneous cholangiography or ERCP may reveal filling defects in the biliary system suggestive of clots, although it is not pathognomonic of haemobilia. Coeliomesenteric angiography is the most rewarding investigation where the commonest finding is the presence of a pseudoaneurysm. Direct extavasation of contrast into the biliary system revealing the arteriobiliary fistula is diagnostic but seen in 25% cases only. An important advantage of this investigation is that it helps to decide the plan of management of haemobilia usually in the same sitting.
Conservative management of haemobilia is associated with high mortality as spontaneous thrombosis of the pseudoaneurysms is rarely noted. So prompt and active management is recommended in the form of surgical or transcatheter endovascular intervention .The surgical treatment includes liver suturing or partial hepatic resection for peripheal lesion and hepatic artery ligation for more central lesion and choecystectomy where the GB is the site of bleeding. However, the surgical morbidity and motrtality can be significantly reduced with transcatheter approach. Angiographic embolisation is aimed at excluding he vascular lesion out of the circulation to avoid filling of the lesion by subsequent collateral formation all the potential feeders of the vascular lesion are embolised e.g. in case of a hepatic artery pseudoaneurysm it is mandatory embolise distal as well as proximal part of the artery bearing the pseudoaneurysm. The embolisation material used may be permanant embolising agent e.g.coils or polyvinyl alcohol (PVA) particles or temporary embolising agents e.g. Gelfoam. Transcatheter embolisation using permanent or temporary embolising agents has become the treatment of choice for control of hemobilia.
In summary, under experienced hands, angiographic control of bleeding as haemobilia has been established as the standard of care with lowest complications.