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Discussion

Hemobilia

The patient presented in the case received chemoembolization. Chemoembolization may be associated with direct toxicities to the stomach or duodenum that can result in ulcerations and bleeding. Therefore a thourough understanding of the side effects of chemoembolization is necessary to achieve an effective differential diagnosis for the patient. Transarterial chemotherapy via the hepatic artery has been shown in several studies to prolong life in patients with primary or metastatic malignancy in the liver. Metastatic lesions in the liver derive their blood supply from the hepatic artery while hepatocytes rely on the portal vein. Transarterial chemotherapy takes advantage of the high first pass hepatic excretion resulting in a high local concentration of drug with low systemic effects. Ten percent of patients may experience significant hepatobiliary toxicity leading to biliary sclerosis. The biliary toxicity is felt to be due to a combination of an inflammatory and ischemic process. Biliary toxicity is a potential side effect because the bile ducts are supplied blood exclusively by the hepatic artery and are therefore subjected to high doses of chemotherapy. Gastritis can be found in 10-20% of patients and actual ulcers occur in 10-15%. Chemotherapeutic agents may gain access to collateral branches of the hepatic artery and cause severe gastric ulcerations. Since metastatic lesions derive a majority of blood supply from the hepatic artery, one strategy to treat them has been to remove this source. Therapeutic modalities that are able to achieve this are hepatic artery ligation and hepatic artery embolization. Chemoembolization is an extension of the strategy used with ligation and embolization of the hepatic artery. The concept is that the drug is trapped by an embolization agent in the tumor.

Hemobilia was first observed in 1654 by Francis Glisson in Cambridge. He described a case of hemobilia in a patient that had sustained a penetrating abdominal wound during a sword duel. The term hemobilia was first used by Sandblom when he described bleeding into the biliary tree following trauma. Hemobilia is an uncommon entity but is in the differential diagnosis of upper gastrointestinal bleeding.

The clinical presentation consists of a triad of symptoms which are abdominal pain, upper gastrointestinal bleeding and jaundice. Only 22% of patients actually have the complete triad of symptoms at some point during their presentation. The bleeding may occur immediately following liver trauma or may be delayed by weeks. Blunt liver trauma is usually secondary to motor vehicle accidents and results in shearing of arteries, veins and bile ducts. Penetrating trauma can directly damage blood vessels and bile ducts predisposing to immediate fistula formation and acute presentation of hemobilia. Bleeding in the biliary tree may manifest itself slowly or acutely with massive bleeding. Rapid bleeding passes directly into the duodenum and presents as hemetemasis or melena. When bleeding is slow, blood and bile do not mix (due to different specific gravities and surface tensions) resulting in clots that can obstruct the biliary system.

Over the past several years, the most common cause of hemobilia is iatrogenic. In reviews of complications due to percutaneous liver biopsy, the incidence of hemobilia is 0.06 to 1%. Those at greatest risk of this complication include patients with ascites, coagulopathy, cirrhosis, and liver transplant. The risk of hemobilia is slightly higher for percutaneous transhepatic biliary drainage (2-10%) and percutaneous transhepatic cholangiography (4%). Surgical exploration of the biliary tree for biliary stones may cause hemorrhage. There are reports of hemobilia associated with choledochoduodenostomy, hepatic lobectomy, and T tubes. Gallstones may cause hemobilia by eroding into a blood vessel. Risk factors that may predispose patients to hemobilia include primary vascular abnormalities such as angiodysplasia and coagulopathy. There have been reports of malignant tumors of the liver, bile ducts, gallbladder and pancreas causing hemobilia. Infectious causes such as hepatic abscess and parasitic infections (ascariasis) may be associated with hemobilia.

Diagnosis of hemobilia may be difficult and relies on esophagogastroduodenoscopy (EGD) and angiogram via interventional radiology. Diagnosis is confirmed endoscopically when blood is seen emanating from the ampulla of vater. If EGD is nondiagnostic and clinical suspicion is high, further investigation with angiogram is warranted. Angiography is now considered the definitive investigation. Technical difficulties may arise with anomalies of the hepatic artery or previous surgery. Angiogram may be normal if bleeding is intermittent. CT is not sensitive in detecting hemobilia, however it can identify those at risk such as patients with cavitating lesions, aneurysms and pseudoaneurysms.

The first line of treatment for most cases of hemobilia is embolization of the hepatic artery by interventional radiology. Hepatic sepsis/abscess is a contraindication to embolization. Surgery is indicated in cases where embolization fails. Surgery involves ligation of the bleeding vessel or excision of the aneurysm (if present).