Obstructive jaundice caused by hemobilia after liver biopsy

Hemobilia due to arteriobiliary duct fistula is a rare complication of percutaneous liver biopsy [1] [2] [3] typically presenting with jaundice, pain, and bleeding [4]. The role of endoscopic retrograde cholangiopancreatography (ERCP) is well established [1] [5]. We report two cases successfully treated with sphincterotomy and clot removal.

Case 1. A 45-year-old woman with a clinical diagnosis of cirrhosis underwent liver biopsy. She had a past history of cholecystectomy. There was no evidence of any complication shortly after the biopsy. After 5 days, although otherwise asymptomatic, she developed jaundice (total bilirubin 5 mg/dL). Abdominal ultrasound showed a slightly dilated common bile duct (CBD). She was referred for ERCP, which demonstrated mild dilation of the CBD with a long longitudinal mobile filling defect ([Fig. 1]) corresponding to a large blood clot filling the whole duct.

Fig. 1 Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated mild dilation of the common bile duct with a long longitudinal mobile filling defect suggesting the presence of a blood clot.

After sphincterotomy the clot was retrieved using a balloon ([Fig. 2]).

Fig. 2 Endoscopic view of a clot being retrieved using a balloon after the sphincterotomy.

Cholangiography following intraductal clot removal demonstrated clearance of the filling defect ([Fig. 3], [Video 1]).

Fig. 3 Occlusion cholangiogram revealing clearance of the bile duct.

Video 1 Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated mild dilation of the common bile duct with a long longitudinal mobile filling defect suggesting the presence of a blood clot. Sphincterotomy was performed and a large clot was retrieved using a balloon. Final occlusion cholangiogram revealing clearance of the bile duct.

The patient recovered uneventfully with no further bleeding.

Case 2. A 37-year-old man with a past history of blood transfusion and elevated liver enzymes underwent liver biopsy. Viral serology findings were negative and autoimmune disease had also been disclosed. There was no evidence of early complications after the procedure. Four days after the biopsy the patient presented with jaundice, fever, and severe abdominal pain. Liver enzymes and bilirubin were slightly raised (total bilirubin 9.3 mg / dL). Abdominal CT scan revealed a mildly dilated biliary tree with the suggestion of an arteriobiliary fistula ([Fig. 4], arrows).

Fig. 4 Abdominal CT scan showing a slightly dilated biliary tree with the suggestion of an arteriobiliary fistula (arrows).

ERCP disclosed an enlarged major papilla obstructed by a blood clot ([Fig. 5 a]).

Fig. 5 a ERCP showed an enlarged major papilla obstructed by a blood clot. b Large blood clots were drained after sphincterotomy.

A large filling defect was present in the dilated CBD suggestive of biliary obstruction resulting from hemobilia. When sphincterotomy was performed, large blood clots were drained ([Fig. 5 b], [Video 2]).

Video 2 Duodenoscopy showed an enlarged major papilla obstructed by a blood clot. After sphincterotomy was performed large blood clots were drained and a balloon was used to clear the biliary tree.

The final occlusion cholangiogram demonstrated no further filling defects and absence of a biliary fistula.

Endoscopy_UCTN_Code_CCL_1AZ_2AO

References

• 1 Sciumè C, Geraci G, Pisello F. et al . An uncommon complication of liver biopsy: obstructive jaundice from blood clots.  Ann Ital Chir. 2005;  76 579-581
• 2 Edden Y, St Hilaire H, Benkov K. et al . Percutaneous liver biopsy complicated by hemobilia-associated acute cholecystitis.  World J Gastroenterol. 2006;  12 4435-4436
• 3 Moon W, Sohn J H, Jang M H. et al . A case of acute cholecystitis secondary to hemobilia after percutaneous liver biopsy [in Korean].  Korean J Gastroenterol. 2006;  47 72-76
• 4 Kroser J, Rothstein R D, Kochman M L. Endoscopic management of obstructive jaundice caused by hemobilia.  Gastrointest Endosc. 1996;  44 618-619
• 5 Worobetz L J, Passi R B, Sullivan S N. Hemobilia after percutaneous liver biopsy: role of endoscopic retrograde cholangiopancreatography and sphincterotomy.  Am J Gastroenterol. 1983;  78 182-184