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Haemobilia is an unusual but significant cause of upper gastrointestinal bleeding. Two-thirds of haemobilia cases are secondary to invasive hepato-biliopancreatic procedures. Biliary angiodysplasia is exceptionally unusual, with only three cases reported. Herein, we report the case of an autonomous 80-year-old woman with a history of cholecystectomy 5 years ago and cardiovascular disease-hypertension, heart failure, acute myocardial infarction, stroke and non-valvular atrial fibrillation, anticoagulated with apixaban 2.5 mg two times per day. Since July 2019, she had four episodes of acute cholangitis of mild-to-moderate severity, having undergone broad spectrum antibiotics treatment and endoscopic retrograde cholangiopancreatography (ERCP), with sphincterotomy and bile sludge extraction. After 3 months, the patient presented with a new episode of acute cholangitis, this time with haemobilia (Quincke's triad). An abdominal CT angiography showed no evidence of active bleeding, with plastic biliary prosthesis left by ERCP. The patient continued presenting new episodes of acute cholangitis with haemobilia, some of them with associated pancreatitis. A cholangioscopy with Spyglass DS II was performed, showing an angiodysplasia occupying half of the luminal circumference of the middle choledoccus, without active haemorrhage. After a multidisciplinary meeting and given the high haemorrhagic/thrombotic risk (CHA2DS2-VASc 8), closure of the left atrial appendage was considered. However, relapse of the condition after beginning the antiaggregation protocol for cardiovascular intervention made it unfeasible. Another cholangioscopy with an ultra-thin endoscope for argon-plasma coagulation was attempted, without success. The abdominal CT angiography was repeated, this time with identification of dilated ramifications of the gastroduodenal and inferior pancreatic arteries. After embolisation of these aberrant vessels with microcoils, the patient went well, with no recurrence of bleeding or biliopancreatic complications. We present a case of obstructive haemobilia with multiple biliopancreatic complications, secondary to an extremely rare cause-choledochal angiodysplasia. Cholangioscopy had a decisive role in the diagnosis and therapeutic guidance. The diagnostic/therapeutic challenge associated with haemobilia stands out, with the need for a personalised and multidisciplinary approach., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

A rare case of arterio-biliary fistula and haemobilia complicating intra-operative microwave ablation of hepatocellular carcinoma in a 58-year-old woman with cirrhosis., (© 2021 The Royal Australian and New Zealand College of Radiologists.)

Background: Hemobilia refers to bleeding into the biliary tract. Hepatic artery pseudoaneurysm (HAP) rupture is an uncommon cause of hemobilia, and cases of HAP associated with Mirizzi syndrome are extremely rare. Although transarterial embolization is recommended as the first-line treatment for hemobilia, surgery is sometimes required., Case Presentation: A 76-year-old woman was referred to our hospital with epigastric pain. She was febrile and had conjunctival icterus and epigastric tenderness. Laboratory tests revealed abnormal white blood cell count and liver function. An abdominal computed tomography (CT) revealed multiple calculi in the gallbladder, an incarcerated calculus in the cystic duct, and a slightly dilated common hepatic duct. Based on examination findings, she was diagnosed with Mirizzi syndrome type I, complicated by cholangitis. Intravenous antibiotics were administered, and we performed endoscopic retrograde cholangiopancreatography (ERCP) to place a drainage tube. The fever persisted; therefore, contrast-enhanced CT (CECT) was performed. This revealed portal vein thrombosis and hepatic abscesses; therefore, heparin infusion was administered. The following day, she complained of melena, and laboratory tests showed that she was anemic. ERCP was performed to change the drainage tube in the bile duct; however, bleeding from the papilla of Vater was observed. CECT demonstrated a right HAP with high-density fluid in the gallbladder and gallbladder perforation. Finally, she was diagnosed with hemobilia caused by HAP rupture, and emergency surgery was performed to secure hemostasis and control the infection. During laparotomy, we found that a right HAP had ruptured into the gallbladder. The gallbladder made a cholecystobiliary fistula, which indicated Mirizzi syndrome type II. Although we tried to repair the right hepatic artery, we later ligated it due to arterial wall vulnerability. Then, we performed subtotal cholecystectomy and inserted a T-tube into the common bile duct. There were no postoperative complications except for minor leakage from the T-tube insertion site. The patient was discharged after a total hospital stay of 7 weeks., Conclusions: We experienced an extremely rare case of emergency definitive surgery for hemobilia due to HAP rupture complicated by Mirizzi syndrome type II. Surgery might be indicated when controlling underlying infections was required., (© 2021. The Author(s).)

Introduction: The laparoscopic approach has become the gold standard for cholecystectomy. However, it could have some major complications. Among them, it can be considered postoperative pseudoaneurysms of the cystic or hepatic arteries. Haemobilia secondary to a cystic artery pseudoaneurysm is extremely rare., Case Report: Here we present a case from our centre of haemobilia in association with a cystic artery pseudoaneurysm, as a late complication of VLC. An 18-year-old girl underwent laparoscopic cholecystectomy; during surgery, due to viscero-perietal tight adhesions and due to the close proximity of the cystic duct to the biliary ducts, we suspected a bile duct injury. So, decision was taken to convert to open surgery: a suture was performed to repair the coledocic duct injury and an endoscopic papillotomy was performed with subsequent positioning of an endoscopic plastic biliary endoprothesis at the hepatocholedochus. One month after surgery, the patient showed clinical signs of hypovolemic shock. She underwent Computed Tomography Angiography, showing a possible arterial lesion, just adjacent to surgical clip. Therefore, patient underwent angiographic examination, which confirmed an 8 mm pseudoaneurysm arising from cystic artery, just adjacent to surgical clips. Superselective catheterization of vessel was performed, and two coils were released, until obtaining complete exclusion of the vascular lesion. The patient was discharged five days after procedure, with good general condition., Conclusion: Pseudoaneurysms of the cystic artery are uncommon entities, rarely reported in the literature, and often caused by cholecystitis or iatrogenic biliary injury. All conditions that are responsible for vessels' injuries could also cause haemobilia. Even if pseudoaneurysm of cystic artery with haemobilia is a rare event, it has to be considered as a complication of VLC. Angiographic approach should be the treatment of choice.

Introduction: Hepatic artery aneurysm (HAA) is a rare occurrence. Quincke's triad of hemobilia; abdominal pain, obstructive jaundice, and upper gastrointestinal (GI) bleeding could be detected in one-third of HAA patients., Case Presentation: We present a case of HAA with all signs of Quincke's triad and shock. The diagnosis of HAA was enforced by CT angiography. An urgent open surgical approach was elected by the surgical team. The patient underwent an uneventful resection of the HAA, and primary repair of the CHA followed with bilioenteric reconstruction., Conclusions: Recognizing the signs of Quincke's triad aids in prompt diagnosis of hemobilia in HAA, which suggests a rupture of the aneurysm or fistula formation into the biliary tree that would need urgent management by both vascular and HBP surgeons., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Gallbladder cancer that presents as acute cholecystitis associated with hemocholecyst and hemobilia is a rare entity. There are few cases reported in the literature. We present a case of gallbladder carcinoma diagnosed after emergency cholecystectomy, performed due to hemobilia and acute cholecystitis due to hemocholecyst., (Copyright: © 2021 Permanyer.)

Background: Hemobilia occurs mainly due to iatrogenic factors such as impairment of the right hepatic or cystic artery, and/or common bile duct in hepatobiliary-pancreatic surgery. However, little or no cases with hemobilia from the intra-pancreatic remnant bile duct after bile duct resection (BDR) has been reported. Here, we report a case of massive hemobilia due to the perforation of psuedoaneurysm of the gastroduodenal artery (GDA) to the intra-pancreatic remnant bile duct after hepatectomy with BDR., Case Presentation: A 68-year-old male underwent extended right hepatectomy with BDR for gallbladder carcinoma. He presented with upper gastrointestinal bleeding 2 months after the initial surgery. Upper endoscopy identified a blood clot from the ampulla of Vater and simultaneous endoscopic balloon tamponade contributed to temporary hemostasis. Abdominal CT and angiography revealed a perforation of the psuedoaneurysm of the GDA to the intra-pancreatic remnant bile duct resulting in massive hemobilia. Subsequent selective embolization of the pseudoaneurysm with micro-coils could achieve complete hemostasis. He survived without any recurrence of cancer and bleeding., Conclusion: Hemobilia could occur in a patient with BDR due to perforation of the pseudoaneurysm derived from the GDA to the intra-pancreatic remnant bile duct. Endoscopic balloon tamponade was useful for a temporal hemostasis and a subsequent radiologic interventional approach.

A hepatocellular carcinoma (HCC) rarely expands into the biliary tract. In this situation, because of its hypervascular nature, cholangitis or hemobilia may sometimes occur. Surgery is one of the options in this situation. However, patients with HCC and bile duct invasion are sometimes in a poor general condition, as in the case presented in this report. For such patients, surgical treatment may need to be invasive. Thus, here we report technical tips for triple covered metal stent deployment using side-by-side technique for hemobilia due to HCC. After guidewire deployments at the left, anterior, and posterior bile ducts, 6-mm covered self-expandable metal stents were placed at each bile duct. This may be useful for high-grade hepatic hilar obstruction due to HCC because drainage and hemostasis effects are obtained., (© 2019 S. Karger AG, Basel.)

Spontaneous right hepatic artery branch gallbladder fistula is a rare condition. Our case reported a spontaneous fistula between the right branch of the hepatic artery and the gall bladder. It constitutes a rare cause of haemobilia. In fact, the most common aetiology of haemobilia is traumatic or iatrogenic secondary to hepatobiliary surgery or interventions. Diagnosis of vascular-biliary fistula is not easy. The gallbladder endoluminal clot can mimic a mass, as in our patient. Selective arterial angiography is helpful in identifying the source of gastrointestinal haemorrhage. It can demonstrate the presence of arteriobiliary fistula. The differential diagnosis is arterial pseudoaneurysm in the vicinity of the vessel. Mini-invasive treatment of this fistula constitutes the best treatment. We here report a case of haemobilia with upper cataclysmic gastrointestinal bleeding revealing a spontaneous fistula between the right branch of the hepatic artery and the gall bladder., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

A 78-year-old woman was admitted with benign biliary stenosis. A plastic stent was placed at the left branch to prevent obstructive cholangitis. Two weeks after the procedure, the patient was readmitted with cholangitis caused by hemobilia. However, computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), peroral cholangioscopy, and abdominal angiography failed to establish the bleeding source. At the seventh bleeding, CT revealed a hepatic artery pseudoaneurysm for which coil embolization was successfully performed. Hemobilia after plastic stent placement is extremely rare. We urge clinicians to consider the possibility of a pseudoaneurysm near the stent when trying to identify the bleeding source.

Background: Gastroduodenalartery (GDA) pseudo-aneurysms are very rare. Their clinical importance lies in the eventuality of rupture, causing bleeding and ultimately exsanguination., Case Presentation: We report the case of a man, with prior history of biliary surgery, presenting with haemobilia secondary to a rupture of GDA pseudo-aneurysm eroding the main bile duct. The patient was treated with coil embolization. This technique is considered to be safe. However, on the long term, some complications may occur. In our case, the patient presented with cholangitis subsequent to coil migration in the lower bile duct. This situation was managed using endoscopic retrograde cholangiopancreatography (ERCP) allowing coil extraction with favorable evolution., Conclusions: GDA pseudo-aneurysms are very rare. Bleeding, secondary to the rupture of these lesions, is a serious complication that could lead to death. Diagnosis and treatment of ruptured GDA pseudo-aneurysms rely on angiography. This method is considered to be safe. Cholangitis secondary to coil migration in the main bile duct is exceedingly rare,but remains an eventuality that physicians should be cognizant of.

Background and Aim: Spontaneous hemobilia is an uncommon liver transplantation (LT)-related biliary complication. The frequency, etiology, and mechanism of spontaneous hemobilia after LT are not known. This study aimed to assess the outcome of endoscopic management for spontaneous hemobilia after LT, and to investigate its frequency and risk factors., Methods: The records of patients who underwent endoscopic retrograde cholangiopancreatography to manage hemobilia after LT at the Asan Medical Center, Korea, between January 2006 and April 2014 were retrospectively reviewed., Results: A total 2701 cases of LT was performed in the study period, and 33 LT patients with spontaneous hemobilia were included in the study group. Endoscopic nasobiliary drainage was achieved in 33 cases (100%). In 29 of 33 patients (87.9%), hemobilia was improved. The frequency of spontaneous hemobilia was 1.22% (33/2701). On multivariate analysis, United Network for Organ Sharing status I or IIa (odds ratio [OR] 3.095, 95% CI 1.097-8.732, P = 0.033), alcoholic liver cirrhosis (OR 3.942, 95% CI 1.261-12.324, P = 0.018), and body mass index < 24.5 kg/m 2 (OR 2.329, 95% CI 1.005-5.397, P = 0.049) were significant risk factors for spontaneous hemobilia after LT., Conclusions: Endoscopic retrograde cholangiopancreatography and endoscopic nasobiliary drainage are feasible methods for the management of spontaneous hemobilia after LT. In patients with United Network for Organ Sharing status I and IIa, alcoholic liver cirrhosis, or body mass index < 24.5 kg/m 2 , special attention should be paid to the occurrence of spontaneous hemobilia after LT., (© 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

A 61-year-old woman presented to our hospital with epigastric pain. She underwent abdominal contrast-enhanced computed tomography, which showed signal enhancement in the gallbladder fundus. As biliary obstruction was suspected, endoscopic nasobiliary drainage was performed, which revealed hemobilia. Based on this finding, gallbladder tumor was suspected, and open cholecystectomy was performed. Immunohistological staining of the resected tissue was positive for factor VIII that led to the diagnosis of gallbladder angiosarcoma. Hepatectomy and biliary reconstruction were performed for disease control; however, the patient died due to multiple liver metastases 4 months after the surgery.

Hemobilia secondary to gallbladder polyposis is rare in children but has been reported in a few children with metachromatic leukodystrophy. We present a case with preoperative multidetector computed tomography (MDCT) diagnosis of massive hemobilia caused by gallbladder polyposis in a patient with metachromatic leukodystrophy. Our report highlights the importance of both awareness of the association of gallbladder polyposis with other syndromes such as metachromatic leukodystrophy as well as the possibility of this entity presenting with life-threatening bleeding.

A 72-year-old man with a history of gallstones, and complex cardiac and endocrinological comorbidities, presented with severe abdominal pain and melaena. CT mesenteric angiogram showed a cystic artery pseudoaneurysm and gallbladder distended by haematoma. Subsequent mesenteric angiography confirmed a cystic artery pseudoaneurysm, which was successfully embolised with microcoils. The patient made a rapid recovery and was discharged after 3 days., (2015 BMJ Publishing Group Ltd.)

Hemobilia is an uncommon presentation of biliary tract or pancreatic disease. The investigation and management of this clinical problem is challenging. We report on a case of biliary tract hemorrhage from an otherwise asymptomatic right lobe biliary cystadenocarcinoma and review the literature on this unusual presentation. Hemobilia from primary or secondary liver tumors is not frequently reported in the literature. Hemobilia in this setting is usually observed in association with an obvious liver mass or abnormal liver function tests. This is a report of a case of hemobilia as the primary presentation of a small right lobe cystadenocarcinoma. Literature on the incidence and treatment of hemobilia associated with liver tumors has been reviewed. Hemobilia is investigated and definitively treated with angiography. In our case, initial imaging was equivocal and the lesion was only demonstrated after rebleeding, requiring a second angiogram. Surgical resection of the mass was required for definitive control of bleeding. This case illustrates the difficulties of investigating and treating hemobilia caused by primary or secondary liver tumors. Cystadenocarcinoma of the liver is not a common tumor, and biliary tract hemorrhage as the primary presentation of this tumor in the absence of a significant mass or abnormal liver function tests has not been previously described.

Hemobilia is an unusual and potentially catastrophic cause of gastrointestinal bleeding. Although hepatic artery aneurysm is a cause of hemobilia, nontraumatic cases are infrequently reported. Herein, we describe the case of a giant hepatic artery aneurysm requiring hepatectomy because of repeated hemobilia in a patient with Marfan syndrome. A 53-year-old man presented to our hospital with sudden epigastric pain and jaundice. Abdominal computed tomography showed a giant hepatic arterial aneurysm in the porta hepatis, and emergency endoscopic retrograde cholangiography revealed hemobilia. Assuming that the aneurysm caused the hemobilia, we performed an abdominal angiogram for treatment. The study revealed a thrombosed aneurysm along with tortuous abnormal vessels in the periphery of the left hepatic artery, which appeared to surround the aneurysm. Therefore, we embolized the left hepatic artery, and immediate hemostasis was achieved. Rebleeding occurred 3 times thereafter, and each time, transarterial embolization was performed, resulting in prompt but only temporary hemostasis. Then, emergency left hemihepatectomy and resection of the aneurysm were performed. Pathologic examination of the resected specimen revealed that the aneurysm was completely thrombosed and organized; however, abnormal arterioles proliferated between the aneurysmal wall and the bile duct. The unique feature of this case was that the abnormal arterioles induced by the organized hepatic artery aneurysm, not the aneurysm itself, caused the hemobilia., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Upper gastrointestinal (GI) bleeding remains a commonly encountered diagnosis for acute care surgeons. Initial stabilization and resuscitation of patients is imperative. Stable patients can have initiation of medical therapy and localization of the bleeding, whereas persistently unstable patients require emergent endoscopic or operative intervention. Minimally invasive techniques have surpassed surgery as the treatment of choice for most upper GI bleeding., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Haemobilia can present with gastrointestinal bleeding, biliary colic and jaundice. Causes include trauma, iatrogenic causes, calculi, inflammation, vascular malformations and neoplasms. Benign gallbladder polyp is a very rare cause. A 63-year-old male with suspected gallbladder cancer due to the results from ultrasound scanning and computed tomography presented with epigastric pain, vomiting, weight loss, dizziness, sweating, fatigue, black stool and low haemoglobin level. Gastroscopy and colonoscopy were normal. Surgery revealed a gallbladder with inflammation, fibrosis, haemorrhage, blood clot and a 2 cm pedunculate polyp with no signs of dysplasia or malignant invasion.

Objective: To study the causes of hemobilia occurring during percutaneous transhepatic drainage and to develop methods for its prevention., Material and Methods: Treatment results were analyzed in 149 patients with tumors in the hepatopancretoduodenal area. Among the examined patients, there were 65 (43.6%) males and 84 (56.4%) females at the age of 33 to 91 years (mean 64.1 years) who underwent 881 different endobiliary interventions. The condition was severe in 46 (30.9%) patients, moderate in 89 (59.7%), and satisfactory in 14 (9.4%). Extensive abdominal surgery had been performed in 71 (47.6%) cases. The preadmission history of mechanical jaundice was 7 to 30 days (mean 18.5 days). Total bilirubin levels were in the range from 32.9 to 726 μmol/l (mean 249.4 μmol/l). Philips Allura V 3000 and Siemens Axiom Artis devices were used to exercise X-ray TV control during the interventions., Results: The bile ducts were stented applying various models of expanding metallic stents in 93 (62.4%) of the 149 patients. A one-stage stenting protocol was used in 24 (25.8%) of the 93 patients and two-stage endobiliary stenting was carried out in 69 (74.2%). The other 56 (37.6%) of the 149 patients underwent only external-internal biliary drainage. Ten (6.7%) patients were noted to have different hemorrhagic complications as venous (4.7%, n = 7) and arterial (2%, n = 3) hemobilia., Conclusion: X-ray surgical hemostatic procedures can ensure a final positive effect of transhepatic bile duct compression.

Background: Haemobilia usually occurs secondary to accidental or iatrogenic hepatobiliary trauma. It can occasionally present with cataclysmal upper gastrointestinal haemorrhage posing as a life threatening emergency. Haemobilia can very rarely be a complication of acute cholecystitis. Here we report a case of haemobilia manifesting as massive gastrointestinal haemorrhage in a patient without any prior history of biliary surgery or intervention and present a brief review of literature., Case Presentation: A 22 year old male admitted with history suggestive of acute cholecystitis subsequently developed waxing waning jaundice and recurrent episodes of upper gastrointestinal bleed. Endoscopy showed an ulcer in the first part of duodenum with a clot, no active bleed was visible. Angiography was suggestive of a ruptured pseudoaneurysm in the vicinity of the right hepatic artery probably originating from the cystic artery. Coil embolization was tried but the coil dislodged into the right branch of hepatic artery distal to the site of pseudoaneurysm. Review of angiographic video in light of operative findings demonstrated a fistulous communication between cystic artery and gallbladder as the cause, a simultaneous cholecystoduodenal fistula was also noted. Retrograde cholecystectomy, closure of cholecystoduodenal fistula and right hepatic arteriotomy with retrieval of the endo-coil and hepatic arterial repair was performed., Conclusion: Fistula between the cystic artery and gallbladder has been commonly reported to occur after laparoscopic cholecystectomy. Spontaneous fistulous communication, i.e. in the absence of any prior trauma or intervention, between cystic artery and gallbladder is rare with very few reports in literature. Aetiopathogenesis of the disease, in the context of current literature is reviewed. The diagnostic dilemma posed by the confounding finding of an ulcer in the duodenum, the iconic video angiographic depiction as also the therapeutic challenge of a failed embolization with consequent microcoil migration and primary hepatic arterial repair in the emergency situation is discussed.

Intrabiliary hydatid cysts have been known to cause complications. We report a rare case of calcified crumpled intrabiliary hydatid cyst causing massive haemobilia due to a hepatic artery pseudoaneurysm, an unusual complication of intrabiliary hydatid cyst. The patient was successfully treated by stenting of the pseudoaneurysm with overlapping stents., (© 2012 The Authors. Journal of Medical Imaging and Radiation Oncology © 2012 The Royal Australian and New Zealand College of Radiologists.)

Biliary papillomatosis is a rare condition usually detected on imaging or postoperative histopathology. It may be asymptomatic or present with features of cholangitis. We report the management of a patient presenting with haemobilia.

A hepatic artery aneurysm is an unusual but life-threatening hepatobiliary complication occurring in patients with systemic lupus erythematosus (SLE), and early diagnosis and treatment of this complication are essential. A 31-year-old man with SLE presented with recurring epigastric pain and jaundice for 2 months; he was diagnosed with choledocholithiasis and underwent surgery. Hemobilia was found intraoperatively, and two hepatic artery aneurysms were identified in the left lateral lobe during postoperative arteriography. Major hemobilia occurred 6 days after the operation, and the patient was immediately treated with selective embolization of the hepatic artery. However, the major hemobilia recurred 2 days later, and he was treated with a left lateral lobectomy and ligation of the proximal hepatic artery. The patient recovered uneventfully and is in good condition. A histological analysis revealed small- and medium-sized arteritis as well as hepatic artery aneurysm. Systemic lupus erythematosus complicated by a hepatic artery aneurysm should be considered in the differential diagnosis of patients showing symptoms of abdominal pain, jaundice, or gastrointestinal bleeding.

Radiofrequency ablation (RFA) is performed as an alternative to surgical resection for primary or secondary liver malignancies. Although RFA can be performed safely in most patients, early and late complications related to mechanical or thermal damage occur in 8-9.5% cases. Hemocholecyst, which refers to hemorrhage of the gallbladder, has been reported with primary gallbladder disease or as a secondary event associated with hemobilia. Hemobilia, defined as hemorrhage in the biliary tract and most commonly associated with accidental or iatrogenic trauma, is a rare complication of RFA. Here we report a case of hemocholecyst associated with hemobilia after RFA for hepatocellular carcinoma that was successfully managed by laparoscopic cholecystectomy.

Background: Portal biliopathy is a late and serious complication of extrahepatic portal venous obstruction usually manifesting with jaundice. Surgery and endoscopic therapy are the usual modalities of treatment for this condition. Endoscopic management contains inherited risk of hemobilia treatment of which is yet to be standardized., Patients and Methods: Retrospective analysis of data from 2002 to 2007 for nonsurgical management of portal biliopathy was carried out. We encountered 4 cases of hemobilia during this period. The management and outcome of these 4 patients was analyzed., Results: Median age at presentation was 39 years (22 to 50 y). All the patients had cholestatic jaundice and pain as presenting symptoms without prior history of gastrointestinal bleed. The median serum bilirubin and alkaline phosphatase values were 5 mg/dL (4.8 to 11.3 mg/dL ) and 494 IU/mL (342 to 645 IU/mL), respectively. Endoscopic retrograde cholangiography documented changes of portal biliopathy along with choledocholithiasis in all the 4 patients. An uneventful endoscopic sphincterotomy was followed by significant hemobilia during attempted stone extraction by Dormia basket/balloon. Patients were resuscitated with standard measures and injection terlipressin was started at a dose of 1 mg 4 times daily. Control of bleeding was achieved within 12 hours of infusion in all 4 patients and there was no bleed-related mortality., Conclusions: All our patients had symptomatic portal biliopathy as their first manifestation of underlying extrahepatic portal venous obstruction. Common bile duct stone extraction in patients with portal biliopathy carries a high risk of hemobilia even with balloon sweeping. Terlipressin is an effective pharmacologic treatment for hemobilia in patients with portal biliopathy.

Objective: To determine the method for locating the hemorrhagic site of biliary tract and assess the value of hepatectomy., Methods: Clinical data of 23 patients with biliary tract hemorrhage undergoing liver segmentectomy between January 1998 and October 2008 were analyzed. There were infection of biliary tract or hepatolithiasis in 14 patients (60.9%), trauma in 6 (26.1%) and primary liver cancer in 3 (10.0%). Precise orientation was achieved by selective angiography in 5 patients and by bile duct exploration in 18. Operative approaches included left hemi-hepatectomy in 6 patients, left lateral lobectomy in 8, right hemi-hepatectomy in 4 and combined right segmentectomy in 5., Results: All cases were successfully treated without any operative mortality. A majority of complications were bile leakage in 2 cases, subphrenic infection in 1, stress gastric ulcer in 1 and acute renal failure in 1. During the follow-up period of 8 months-10 years in 15 patients, 3 died of recurrent or metastasis liver cancer and 2 biliary cirrhosis., Conclusion: Hepatectomy is advocated for the management of biliary tract hemorrhage if bleeding is localized to a definite segment and the patient can tolerate the procedure.

The Authors report the clinical case of polytraumatized patient who has colic abdominal pain and Murphy sign after 68 days from damaging event. This symptomatology is consequent to Acute Acalculous Cholecystitis (ACC) associated with hemobilia. This work may be different because hemobilia in polytraumatized patient, like causal factor of acute cholecystitis, is an isolated case in literature. The Authors discuss on ACC risk factors, diagnosis and therapy.

Background: Intrahepatic arterial aneurysms are rare and typically related to trauma, transplantation, iatrogenic injury, or infection. They account for approximately 10% of clinically significant hemobilia., Case Report: We present the case of a 49-year-old man with an intraparenchymal hepatic artery aneurysm that presented as massive hemobilia following a laparoscopic cholecystectomy. The aneurysm could not be managed by interventional embolization and required a left hepatic lobectomy, which was performed laparoscopically., Discussion: Evaluation of hemobilia requires a multidisciplinary team approach. The diagnosis of hepatic artery aneurysm can be most readily made by MRI or CT scan. Interventional embolization of the aneurysm may be effective treatment but is not always possible due to anatomic considerations. Where indicated, surgical resection in a manner that preserves a maximal amount of normal hepatic parenchyma is the treatment of choice., Conclusion: This is the first report of laparoscopic liver resection performed for bleeding from a hepatic artery aneurysm and adds an effective treatment modality to the surgical armamentarium.

Hemobilia or hematobilia is defined by bleeding inside the bile duct. Although rare and misunderstood, it may evolve a life-threatening condition and its frequency is increasing. Clinical presentation commonly includes upper gastrointestinal bleeding, biliary colic and jaundice. The diagnosis must be suggested in a patient with a history of hepatic surgery, trauma or invasive biliary intervention. Key investigation is selective angiogram which allows us to confirm the diagnosis, locate and in most cases treat the vascular lesion responsible of hemobilia. Surgery should remain limited to extra-hepatic or gallbladder bleeding and in case of a failure of intra-vascular embolization.

An isolated gall-bladder injury after blunt abdominal trauma is rare. Intraluminal bleeding with a perforation and an intra-abdominal haemorrhage is even rarer. Early diagnosis is difficult, even with a CT-scan or an US-scan available. Clinical suspicion, serial clinical examination and repeated imaging, can prevent mortality and morbidity. We present a case where laparoscopy was used to diagnose and treat an isolated gall-bladder lesion after blunt abdominal trauma.

Cytomegalovirus (CMV) cholangitis is a rare manifestation of CMV infection that has previously been described only in HIV-infected patients and solid-organ-transplant recipients. Reported here is a case of CMV cholangitis that occurred in a patient on chronic corticosteroid therapy who presented with recurrent hemobilia and biliary obstruction and was successfully treated with ganciclovir and cholecystostomy. A search of the medical literature revealed no previous case of this kind.

Unlabelled: We studied developments in indication, operation time, conversion rate, morbidity, and mortality from the beginning of laparoscopic cholecystectomy. Between 1990 and 2002 we prospectively evaluated 4498 patients undergoing cholecystectomy (CE), of whom 79% were treated laparoscopically (lap). In 6.6%, the procedure had to be converted from laparoscopic to open cholecystectomy (con), and 14% were performed open from the beginning (open). During the above time period, the rate of open CE decreased steadily (49% in 1990 to 7.2% in 2002). The average operation time of lap CE remained constant with an average of 74 min (range 20-330). The conversion rate decreased in spite of broader indication for lap CE in even more complicated gallstone diseases, from an initial 9.4% to 2.5%. Among intraoperative complications in lap and con, bile duct lesions remained constant with 5/3856 (0.1%), bleeding which led to conversion decreased from 1.9% to 0.3%, and the rate of gall bladder perforation increased from 12% to 20.5%. Thirty-day morbidity was 2% in lap CE, 5% in con, and 11.5% in open. The mortality was 0% in lap, 0.7% in con, and 1% in open., Conclusion: Since the introduction of laparoscopic cholecystectomy the indication for this minimal-invasive operation steadily increased, the conversion-rate decreased and the complication-rate could be held low. Even with fast laparoscopic experience 7% of all cholecystectomies are technically difficult and remain to be carried out primarily in an open technique. The laparoscopic cholecystectomy has become the gold standard in the therapy of gallstone disease.

Outpatient percutaneous liver biopsy is a common practice in the differential diagnosis and treatment of chronic liver disease. The major complication and mortality rate were about 2-4% and 0.01-0.33% respectively. Arterio-portal fistula as a complication of percutaneous liver biopsy was infrequently seen and normally asymptomatic. Hemobilia, which accounted for about 3% of overall major percutaneous liver biopsy complications, resulted rarely from arterio-portal fistula We report a hemobilia case of 68 years old woman who was admitted for abdominal pain after liver biopsy. The initial ultrasonography revealed a gallbladder polypoid tumor and common bile duct (CBD) dilatation. Blood clot was extracted as endoscopic retrograde cholangiopancreatography (ERCP) showed hemobilia. The patient was shortly readmitted because of recurrence of symptoms. A celiac angiography showed an intrahepatic arterio-portal fistula. After superselective embolization of the feeding artery, the patient was discharged uneventfully. Most cases of hemobilia caused by percutaneous liver biopsy resolved spontaneously. Selective angiography embolization or surgical intervention is reserved for patients who failed to respond to conservative treatment.