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One new case of post-traumatic hematobilia due to an arteriobilary fistula is reported. This etiology is relatively rare, and its diagnosis is sometimes difficult if the three signs: pain, bleeding and jaundice are not observed. The most effective paraclinical examination still is selective arteriogrpahy, which makes the diagnosis possible, accurately locates the fistula and sometimes allows hyperselective embolization, as it did in this case. The use of embolization for the treatment of post-traumatic hematobilia due to an arteriobiliary fistula reduces operative mortality for this disease, which still has a poor prognosis.

From 1978 to 1987, thirty patients were secondarily referred to Saint-Antoine Hospital for the treatment of their hepatic trauma. Seventeen were referred because of a postoperative complication (group I) and thirteen after peri-hepatic packing (group II). In group I, transfer was decided because of hemorrhage (8 patients), sepsis (6 patients) and haemobilia (3 patients). The lesions observed in this group (hemoperitoneum, hepatic sequestrum, intrahepatic hematoma, choleperitoneum and subphrenic abscess) were often related to an incomplete assessment of hepatic damage due to an inadequate exploration and the absence of operative cholangiography. In group II, peri-hepatic packing was effective in eleven patients. The overall mortality was 16.6% (17.6% in group I and 15.4% in group II). Postoperative complications occurred in 50% of the patients (64.6% in group I and 30.7% in group II). Good exposure of the liver, operative cholangiography and, in selected cases, a direct approach to the lacerated liver with suture ligation of severed blood vessels and bile ducts are mandatory for the complete exploration and the treatment of severe hepatic trauma. Peri-hepatic packing and the transfer of the patient to a specialized center is a reliable method when the injury cannot be treated locally.

The surgical management of traumatic hemobilia by direct ligation of the bleeding vessel is described in two children. The operative procedures were performed with ease and without postoperative problems. Other available operative procedures are also discussed. Direct ligation of the bleeding vessel is recommended as the operative procedure of choice.

The authors report on the first case of haematobilia diagnosed in childhood by means of sonography. Massive haematemesis occurred in a six-year-old boy on the 57th postoperative day after an oversewn rupture of the liver. Sonography revealed an atonic gallbladder with stratification phenomena and free floating highly reflecting coagulates, as well as pulsations and flow phenomena in an area of the size of a bean at the floor of a necrotic cavity of the liver (aneurysm). Relaparotomy was done by locating the aneurysm via sonography and performing a purse-string ligature. The high mortality rate of 10 to 20% can be reduced if the gradually evolving condition is identified at an early stage, which means that regular sonographic examinations should be conducted in the postoperative control of liver rupture. Intraoperative sonography with sterilisable sound heads enables accurate location of the source of bleeding.

According to the authors' data the incidence of relaparotomies after 1500 operations for non-tumor diseases of bile ducts was 2.5%. Causes of relaparotomies at early and late terms of the postoperative period were different. The dependence of results of the treatment on the amount of relaparotomies and the presence of such complications as jaundice, cholangitis and pancreatitis has been established. In such complications and increased amount of relaparotomies lethality was considerably higher. General lethality after relaparotomies was 49%. Complex of prophylactic and curative measures of the complications resulting in relaparotomies has been developed.

Selective hepatic artery ligation has traditionally been considered dangerous by some authors in the treatment of traumatic haemobilia. Having observed one case in which this technique was successful in controlling liver haemorrhage, the authors have reviewed the literature. Conditions in which selective hepatic artery ligation can be dangerous are discussed. The safety and effectiveness of this treatment of traumatic haemobilia in normovolemic patients is emphasized.

Haemobilia occurred in a 61-year-old patient 30 days after intraoperative liver biopsy. The bleeding was so severe that left-sided lobectomy of the liver had to be performed.

The use of hepatic artery ligation (HAL) in various clinical situations is illustrated by presenting a series of eight patients. The indications for HAL included ruptured hepatic tumors, spontaneous liver rupture, delayed hemorrhage after liver trauma, hematobilia, hepatic artery aneurysm, and hemorrhage after liver biopsy. Conventional methods of hemostasis had been used in some of these patients, but failed to control hemorrhage. The reasons for the relatively late adoption of hepatic artery ligation in treating liver hemorrhage are discussed and placed in proper prospective. Hepatic artery ligation has been shown to be such an effective method of controlling hemorrhage from the liver that other methods, such as packing and mass suture, which are unsafe and ineffective, should be abandoned. Major resection should be done only when an entire lobe of the liver is reduced to pulp or when exposure and repair of the retrohepatic vena cava are necessary.

The authors describe the use of neodymium yttrium aluminum garnet laser introduced via a percutaneous catheter track for photocoagulation of a bleeding bile duct tumor.

A case of traumatic haemobilia following closed injury is presented. A false aneurysm of the right hepatic artery was successfully treated by inadvertent subintimal stripping of the origin of the right hepatic artery.

A 29-yr-old woman developed portal hypertension secondary to congenital intrahepatic multiple microhamartomata. Percutaneous liver biopsy was complicated by both bile peritonitis and hemobilia. Endoscopic retrograde cholangiopancreatography was used to demonstrate the bile leak. Abdominal paracentesis failed to control the leak, which was managed by surgery. Endoscopic drainage by nasobiliary intubation with suction might have avoided surgery.

A 16-year-old girl with hepatic artery aneurysm due to fibromuscular dysplasia which caused hemobilia is presented. This most unusual and life-threatening type of gastrointestinal bleeding was successfully treated by ligation of the common hepatic and gastroduodenal arteries. The clinical aspects and operative procedures of hepatic artery aneurysm are discussed.

Hemobilia is caused by a pathological communication between the biliary tract and the intra- and extrahepatic blood vessels; multifarious pathogenetical mechanisms of this syndrome have to be considered. The trias of colicky upper abdominal pain, jaundice and haemorrhage in the upper gastrointestinal tract determinates the clinical picture. To ensure the diagnosis and to localize the source of bleeding sonography, endoscopic retrograde cholangiography (ERC) and coeliacography are indispensable. Besides the transvasal selective embolization ligature of the hepatic artery resection of the affected part of the liver just as reconstructive vascular operations serve as therapeutical tools in this disease. A patient complaining of intrahepatic hemobilia is described who was successfully treated by highly selective ligature of the respective vessel after intraoperative angiography through the stump of the cystic artery. Using this procedure the resection of the affected part of the liver could be avoided.

Many wounds of the liver are minor and require no corrective operations. If these patients are not killed by associated injuries, they usually survive. Hemorrhage from hepatic wounds is the most common cause of death. Selective ligation of appropriate blood vessels swiftly controls bleeding and does not cause septic hepatic necrosis because the liver in humans is sterile and collateral blood flow prevents complete infarction of hepatic tissue. Hepatic resection is dangerous in acutely hypovolemic patients, but hepatic resection is beneficial in treating the late complications of hepatic trauma. Liver-related sepsis after trauma to the liver can be obviated by elimination of gauze packs, absorbable hemostats, peritoneal drains, sutures and choledochal tubes.

Twenty-one patients developed complications of central liver injuries requiring reoperation 1 week to several years after the initial injury. Seven patients were from a series of 320 acute liver injuries treated by us, and 14 were referred to us when their complications became evident. Eleven patients had hepatic abscesses, six had sterile hematomas, and four had hemobilia and its sequelae. Seven patients had asymptomatic vascular disruptions detected with angiography. Two patients developed biliary calculi secondary to hemobilia. Treatment was individualized and ranged from hepatostomy to extended hepatic resection. There were four deaths, three of which were related to the liver injury. Iatrogenic factors were responsible for 62% of these complications. The creation of a central hepatic cavity by superficial suturing or by packing was the most frequent cause, but inadequate resection, failure to provide posterior drainage, and hepatic artery ligation were implicated as well. Late complications of central liver injuries should be infrequent, often are preventable, are not subtle, and respond well to established modes of therapy.

The authors report a case of hemobilia in a ten-year-old boy after abdominal trauma. An intrahepatic false aneurysm was successfully embolized during the diagnostic angiogram. This is, to their knowledge, the first pediatric case successfully embolized with posttraumatic hemobilia.

Hemobilia is a relatively rare manifestation of hepatobiliary disease that is usually characterized by recurrent colicky upper abdominal pain, gastrointestinal bleeding, and obstructive jaundice. In most instances, hemobilia presents as complication of liver injury, blunt abdominal trauma, or liver surgery. Other causes are percutaneous diagnostic procedures, hepatic artery aneurysms, inflammatory disease, biliary tract stones, and liver and bile duct neoplasms. The diagnosis of hemobilia is confirmed by endoscopy and selective angiography. Treatment of hemobilia is primarily surgical, with direct exploration of the liver, ligation of the bleeding point, and relief of bile duct obstruction. If liver damage is minimal, nonoperative management may be successful but requires careful observation and serial arteriography.

Two cases of hepatic artery aneurysm are presented. Both occurred as complications of cholecystectomy for gallstone disease. The aneurysm ruptured in both cases leading to very stormy clinical courses and resulting in the death of one patient. The subject of hepatic artery aneurysms is reviewed and proposals for management are made based on the collective experience reported in the literature.

Diagnosing posttraumatic haemobilia is difficult since the symptoms are neither specific nor early or easy to detect. At present the mortality rate comes up to 20%. Clinical signs and diagnostic procedures are described in detail. Selective ligation of the liver arteries or partial resection of the involved lobes of the liver seem to be the best treatment. 3 cases are presented.

Report of three cases of injury to the bile ducts, of which one was a haemobilia, and two were ruptures of the hepatic ducts with external bile fistulae. The latter could be removed using tissue adhesive (blue Histoacryl). After an observation period of 4 years, no symptoms are noted; there are no calcifications in the area of the erstwhile fistulae. The haemobilia was cured by ligature of the right hepatic artery.