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Critical Care |

Not All Upper Gastrointestinal Bleeding Is Made Equal

Ahmed Abuzaid, MBBCh; Mohamed ELkhashab, MBBCh
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Creighton University, Omaha, NE


Chest. 2014;146(4_MeetingAbstracts):292A. doi:10.1378/chest.1991762
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Abstract

SESSION TITLE: Critical Care Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: The triad of biliary colic, upper gastrointestinal bleeding, and obstructive jaundice is rare and is classically seen in Hemobilia. Bleeding can be massive and a high index of suspicion potentially lifesaving

CASE PRESENTATION: A 46 year old female presented to the ED with colicky epigastric pain and hematemesis. She also had been experiencing fatigue and itching . Her past medical history was notable for complicated laparoscopic cholecystectomy about 8 months ago. Physical examination was significant for icterus and epigastric tenderness. Laboratory evaluation revealed anemia, leukocytosis, elevated direct bilirubin, alkaline phosphatase, transaminases, amylase, and lipase. Abdomenal ultrasound revealed a dilated common bile duct (CBD). Esophagogastroduodenoscopy (EGD) showed blood in the duodenum without any obvious bleeding source. Following this, endoscopic retrograde cholangiopancreatography (ERCP) noted hemobilia. The cholangiogram was significant for presence of a markedly dilated CBD and intra hepatic bile ducts. Multiple balloon sweeps were performed with removal of large amount of clots. A fully covered biliary metal stent was placed in the CBD to facilitate biliary drainage as well as to tamponade a possible bleeding source as she had persistent hemobilia during the procedure. The patient stabilized initially with no further drop in hemoglobin and resolution of her jaundice. However, after two days she had a sudden drop in hemoglobin following which a CT of the abdomen revealed a 2.1 x 1.2 cm pseudoaneurysm of the hepatic artery. The previously placed biliary stent was abutting the pseudoaneurysm. Successful coil embolization of the pseudoaneursym was performed following which the patient’s symptoms improved. The diagnosis of hemobilia caused by pseudoaneurysm of the hepatic artery was established

DISCUSSION: Hemobilia is an unusual cause of upper gastrointestinal bleeding. Etiologies include trauma after hepatobiliary procedures, hepatobiliary neoplasms and vascular lesions of the hepatic artery, cystic artery or portal vein. The clinical presentation of hemobilia is usually obscure and the diagnosis of hemobilia requires a high index of suspicion in patients presenting with upper gastrointestinal bleeding in context of prior manipulation of the biliary system. The classic hemobilia triad includes upper gastrointestinal hemorrhage, biliary colic and obstructive jaundice. In patients who have obstructive jaundice or cholangitis, ERCP should be performed for biliary drainage until a definitive therapy for hemobilia can be undertaken. Abdominal angiogram is diagnostic and therapeutic in the majority of cases. Surgical management is reserved for patients who fail angiographic embolization.

CONCLUSIONS: Hemobilia is an unusual cause of upper gastrointestinal bleeding. Early diagnosis is key in reducing mortality and morbidity related to this condition.

Reference #1: Baillie J. Hemobilia. Gastroenterol Hepatol (N Y). 2012 Apr;8(4):270-2.

DISCLOSURE: The following authors have nothing to disclose: Ahmed Abuzaid, Mohamed ELkhashab

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