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Gut, 1980, 21, 541-544
Case report
Treatment of haemobilia by selective arterialembolisationE A
FAGAN,* D J ALLISON, V S CHADWICK, AND H J F HODGSON
From the Departments of Medicine and Radiology, Royal
Postgraduate Medical School,Hammersmith Hospital, London
SUMMARY We report a patient in whom haemobilia occurred after
percutaneous liver biopsy.Selective hepatic arteriography showed a
fistula between hepatic artery and portal venous system,with
appearance of contrast in the biliary tract. Intrahepatic bleeding
was stopped by arterialembolisation with a mixture of gelatine foam
and sterile dura mater. Cholecystectomy was subse-quently required
as a haemocholecyst developed. The technique of arteriography and
embolisationallows accurate localisation of intrahepatic bleeding
sites and may avoid the need for a directsurgical approach to this
problem.
In a prospective study, 7% of patients undergoingpercutaneous
liver biopsy developed scintigraphicevidence of intrahepatic
haematomas.' Significanthaemobilia, haemorrhage into the biliary
tree, ishowever, extremely rare after this procedure.Between 1967
and 1977, 13 patients with haemobiliawere reported in the
literature.2-1' Three of thosepatients died. A variety of
management approacheshave been used, ranging from aggressive
surgery toconservative management. We report a patienttreated by
arterial embolisation during hepaticangiography and advocate this
approach.
Case report
A 45 year old Pakistani woman was admitted with asix day history
of jaundice, pain in the right upperquadrant, fever, dysuria, and
rash. She had takendihydrocodeine, sulindac, and cotrimoxazole.
She was a thin, icteric woman without stigmata ofchronic liver
disease. Abdominal examination re-vealed tender hepatomegaly and
the spleen was justpalpable.The haemoglobin was 12.6 g/dl and
leucocyte
count, platelets and coagulation screen werenormal. Serum
bilirubin was 200 ,tM/l (n< 14).Aspartate amino transferase 246
IU/1 (n
-
Fagan, Allison, Chadwick, and Hodgson
.Z.......... patient remains well with normal haemoglobin and10X
l cliverfunction tests.
~~~~~~~ ~~~~~Discussion
F. 1 In this particular patient, haemobilia after percu-taneous
liver biopsy was not a diagnostic problem;
.... ... ~~~~~~~shepresented the classical symptom complex
ofbiliary colic, jaundice, and gastrointestinal haemor-rhage, and
endoscopy confirmed the diagnosis by
obi ohowing fresh blood emerging from the ampulla ofVater. The
management of this complication, how-ever, remains difficult. In
three of the 13 patientsreported in the literature, bleeding ceased
spon-
Totaneously after a period of conservative managementwas:~:::~
with transfusion alonew4e5 8 but one fatality has
followed this approach.10 Bleeding may also recurafter a period
of some weeks.8 Experience with
'stonshaemobilia after blunt trauma to the abdomen hasencouraged
a policy of early surgical intervention'2
ated.....~ ~ ~ and some patients have therefore been treated
withmajor procedures including hemi-hepatectomy and
\ v~~~~~~~~~ ~~hepatic artery ligation47 these procedures have
a.significant mortality of their own, particularly in
~~~~~\ ~~~~~~~~~~\ '~~~~~~~~~~~~~
Fig. 1 Selective hepatic arteriogram Early arterialphase with
early portal vein filling at site offistulater nt(arrow).
Angiography at the end of this procedure confirmedobliteration
of the vascular supply to the abnormalsegment, while the remainder
of the liver was un-affected (Fig. 3). After the procedure, the
patient'spain ceased, with no further evidence of bleeding.Two
weeks after embolisation, the patient com-
plained of a new constant pain over the liver. Shewas well and
apyrexial with minimal jaundice buta firm, mobile, and tender
gallbladder was nowpalpable. Ultrasound showed an enlarged,
thickenedgallbladder with echogenic areas interpreted as'stones and
sludge', a dilated cystic duct but normalbile ducts. Repeat
gastroscopy and scintiscan
werenormal.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..
...Alaparotomywasperformed. The gallbladder
was~~~~~~~~~~~~~~~~~~~~~~~~~~..........oedematous,full of blood
clot and clot was evacu-~~~~~~~~~~~~~~~~~~.... .....t
aaooywspromdhe gallbladderhawoaeesopoisdbh
embolisation procedure. A cholecystectomy wasperformed and
T-tube cholangiogram 14 days POSt- Fig. 2 Selective hepatic
arteriogram. Late phaseoperatively was normal. Six months later the
showing contrast medium in common bile duct (arrow).
542
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ut: first published as 10.1136/gut.21.6.541 on 1 June 1980.
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Treatment of haemobilia by selective arterial embolisationi
543
patients with diffuse parenchymal liver disease. Twoof the six
patients undergoing such surgical pro-cedures for control of
haemobilia died.4 Obviouslyno conclusions can be drawn from
comparisonsbetween such small numbers of patients, and assess-ment
of the results of different forms of therapy maywell be made more
complicated by bias againstreporting fatalities.The direct
arteriographic approach used here has
a number of advantages. In the 10 patients in whomit has been
used the bleeding site has been accuratelylocated in all but one.6
This is of particular advantageif gastrointestinal haemorrhage
after liver biopsy isnot associated with either biliary colic or
definitefindings at endoscopy. Furthermore, definitivetherapy can
be instituted. One possible approach wasused by Lee et al., who
infused adrenaline andpropranolol into the right hepatic artery.
After ahalf-hour infusion and after severe pain had de-veloped,
bleeding stopped. The other approach isthat of direct embolisation
of the bleeding site.
...
............ .....*.
*.. .C
... ... .... ... .... .. ... ... ..
Fig.3 Selective hepatic atrtel iogramii aftere*bolisation
Segment containing site of at teriovenoufistula fails to opacify
(arroa)a
This has been used in two previous cases of post-liverbiopsy
haemobilia,9 11 and has also been used for thetreatment of
haemobilia after blunt trauma to theliver.1314 Direct embolisation
of the arteriovenous-biliary fistula in our patient led to the
immediaterelief of pain and cessation of haemorrhage, thelatter
confirmed angiographically. Highly selectiveembolisation was
possible as a steerable cathetercould be positioned sufficiently
close to the bleedingsite. It is clearly desirable that only a
small propor-tion of the liver be deprived of its arterial
bloodsupply, particularly in the presence of generalisedliver
disease; even when such a selective approach isnot possible, emboli
tend to stream in towards areasof high blood flow and thus are
likely to obliteratearteriovenous fistulae at biopsy sites.
Emboliconsisting of gelatine foam with collagen were used,as there
is evidence that this combination producespermanent closure of
vascular anomalies.15 In a caseof haemobilia after blunt trauma
treated withembolisation by gel foam alone, recurrence of a
falseaneurysm was documented and repeat embolisationwas required.'4
A further advantage of arteriographyis that accurate localisation
of the bleeding site anddemonstration of the hepatic vascular
anatomyprovides valuable information for the surgeonshould
embolisation prove impossible or un-successful.
In the patient treated here, although haemorrhagewas
successfully arrested by arteriographic embolisa-tion, surgery was
eventually required for a haemo-cholecyst, a well-described
complication of haemo-bilia. The procedure required to remove the
bloodclot from the biliary tree was considerably lesshazardous than
a direct approach to the bleedingsite. Similarly, in the first
patient treated with thisprocedure, by Walters et al., haemorrhage
wassuccessfully arrested after embolisation of a
bleedingarteriovenous fistula. Subsequent evacuation of alarge
intrahepatic haematoma was necessary, how-ever, to relieve pain. We
do not know whetherembolisation earlier in these two patients would
haveprevented the development of these complications.De Villasante
and his colleagues successfullyembolised a bleeding hepatic artery
14 days afterbiopsy and surgery was not required.
In patients who are continuing to bleed into tHicbiliary tree
after percutaneous liver biopsy, directembolisation of the biopsy
site at arteriographyappears to offer a safe and effective means
oftreatment.
References
'Raines DR, Van Heertum RL, Johnson LF. Intrahepatichematoma: a
complication of percutaneous liverbiopsy. Gastroenterology 1979;
67: 284-9.
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544 Fagan, Allison, Chadwick, and Hodgson
2Cox EF. Hemobilia following percutaneous needlebiopsy of liver.
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