What is Hemobilia & How is it Treated?

Hemobilia is a condition where the patient has bleeding into the biliary tree because of a fistula formation between the intrahepatic or extrahepatic biliary system and the vessel of the splanchnic circulation. Symptoms of hemobilia consist of acute upper gastrointestinal bleeding and upper abdominal pain, especially if the patient has a history of liver instrumentation or injury. The most commonly injured abdominal organ is our liver and hemobilia causes complication in about 2% of patients suffering from significant liver injuries.

The most common cause of Hemobilia is trauma, which can be from accidents or it could be from certain surgical procedures, such as cholecystectomy, inflammatory conditions such as ascariasis, or other conditions such as tumors, vascular malformation, coagulopathy and liver biopsy.

Like mentioned before, posttraumatic hemobilia is a common cause for this condition and accounts for more than half of the Hemobilia cases. Automobile accidents and violent crimes where there is blunt and penetrating injury to the liver can also cause hemobilia. Management of hepato-biliary diseases from use of intubation techniques and percutaneous biopsy also leads to injury of the liver and results in Hemobilia.

The primary symptom of Hemobilia is Quincke’s triad, which is present in about 23% of patients and consists of:

• Upper gastrointestinal hemorrhage (bleeding).
• Pain in the upper abdomen.
• Jaundice.

If the patient has severe bleeding, then it can be extremely fatal. In case of minor hemobilia, patient often will be stable hemodynamically even if there is severe blood loss apparent.

For making the right diagnosis of hemobilia, it is important to first rule out other common causes of upper gastrointestinal tract bleeding. Tests such as CT scan, angiography and esophagogastroduodenoscopy (EGD) and their combination are carried out. Investigations depend on the clinical situation of the patient. It should also be born in mind that hemobilia can be present even after many days have passed after the injury. Cholangiography is done if ERCP is undertaken or if there is a percutaneous access.

In most of the patients, minor bleeding of hemobilia resulting from instrumentation resolves spontaneously without any treatment.

Treatment depends on the cause of hemobilia. The specific anatomy should be carefully assessed before deciding on the treatment options, such as whether to go for angiography or surgery. If the biliary tree is accessible through a percutaneous tube tract, then success for photocoagulation or electrocoagulation using biliary endoscopy is good. Sometimes, the preoperative tests can be negative, and surgical exploration can be the only diagnostic and therapeutic option available.

If there is severe bleeding, then treatment aims at stopping the bleeding and clearing any obstruction present so there is restoration of the bile flow. Some of the modalities for achieving this include angiography with embolization, surgical intervention, and photocoagulation or electrocoagulation. After careful consideration the doctor needs to decide between endoscopic embolization and surgical ligation of hepatic artery.

Trans-arterial embolization (TAE): The preferred method is trans-arterial embolization (TAE), as it has fewer complications and a high success rate. In this procedure, there is selective catheterization of a hepatic artery and then embolic occlusion. Surgery needs to be done if the TAE is not successful.

Angiography: This is also considered an efficacious method for controlling the source of the intrahepatic bleeding and has a very high success rates. Angiographic embolization is proven to be beneficial in controlling extrahepatic bleeding even if the surgery has failed. 

Surgery is needed in cases where the patient has bleeding from the gallbladder mucosa or bile duct tumors. Other than this, if the patient has scarring from previous surgeries, then it hinders the surgical effectiveness for treating hemobilia. In such cases, the exact anatomy of the patient should be assessed for hemobilia from extrahepatic regions, and if it is technically possible and is safe, then embolization should be considered. However, surgery is very successful in controlling intrahepatic hemobilia. Surgery is also helpful in patients who have hemobilia as a result of blunt trauma to the liver, where drainage, debridement and vessel ligation becomes necessary. Placement of drains helps in reducing the possibility of bile pooling. 

Surgery should also be considered in cases where the underlying cause of hemobilia is a condition, which also requires surgery to fix it, such as cholecystitis, cholelithiasis or resectable neoplasms. 

Observation: Expectant observation is done for managing hemobilia in cases where the bleeding occurs as a result of liver biopsy or percutaneous cholangiography; in which case, the bleeding will spontaneously cease.