Umer Farooq, MD1, Akshata Chaugule, MD1, Amlish Gondal, MD2, HMS Arshad, MD3, Joseph Bresnahan, MD1; 1Loyola Medicine/MacNeal Hospital, Berwyn, IL; 2Guthrie Robert Packer Hospital, Sayre, PA; 3Medical College of Georgia at Augusta University, Augusta, GA
Introduction: Hemobilia is a rare cause of upper gastrointestinal bleeding (UGIB) and presents with symptoms of acute bleeding, biliary colic, and obstructive jaundice. Common causes include liver trauma, vascular malformations, and tumors. The reported incidence of hemorrhagic complications during hepatobiliary instrumentation is less than 3.5%. We present a case of hemobilia with the atypical presentation following laparoscopic cholecystectomy.
Methods: An 80 year-old man with multiple medical problems including atrial fibrillation on anticoagulation presented with left lower quadrant abdominal pain, one week after laparoscopic cholecystectomy. Admission laboratory data revealed hemoglobin (HGB) 14.4 g/dL and mild cholestatic elevation of liver enzymes. Computed tomography (CT) of the abdomen showed sigmoid diverticulitis, but no biliary pathology. During the 2-day hospitalization, liver enzymes improved, and hemoglobin downtrended to 12.4 g/dL without signs of overt bleeding. The patient was discharged with oral antibiotics for diverticulitis. One week later, he was readmitted for diffuse abdominal pain. Laboratory workup showed HGB 12.4 g/dL, ALT 489 U/L, AST 645 U/L, ALP 402 U/L, total bilirubin 6.5 mg/dL and GGT 671 U/L. Repeat CT demonstrated interval resolution of the diverticulitis and a hyperdense shadow in the bile duct (Figure 1, 2). Abdominal ultrasound showed an 8.5 mm dilated common bile duct. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), revealing complete obstruction of the middle and distal thirds of the main bile duct by a blood clot that was removed (Figure 3). His abdominal pain resolved, and liver enzymes downtrended during hospitalization. Discussion: This case demonstrates that the classic hemobilia triad (gastrointestinal bleeding, right upper quadrant abdominal pain, hyperbilirubinemia) is not always present. The obscure nature of UGIB due to initial HGB drop followed by stabilization and undulating pattern of liver markers made this case diagnostically challenging. In our patient, hepatobiliary injury during cholecystectomy combined with anticoagulation caused the bile duct hematoma. The diagnostic test of choice to identify the clot and source of bleed is CT angiography. Our case demonstrates that hemobilia should not be overlooked when evaluating elevated liver enzymes in patients with recent hepatobiliary instrumentation, even without obvious markers of gastrointestinal bleeding.
CT scan with hyperdensity
Hyperdense shadow filling CBD on CT scan
Disclosures: Umer Farooq indicated no relevant financial relationships. Akshata Chaugule indicated no relevant financial relationships. Amlish Gondal indicated no relevant financial relationships. HMS Arshad indicated no relevant financial relationships. Joseph Bresnahan indicated no relevant financial relationships.