Baystate Medical Center Springfield, MA, United States
Syed Hamza Sohail, MD, Bushra Zia, MD, Tiago Martins, MD, John W. Miller, MD Baystate Medical Center, Springfield, MA
Introduction: Hemobilia is described as bleeding from biliary tree and is a rare cause of upper gastrointestinal bleeding (UGIB). We present a case of benign hemobilia from a large gallstone leading to biliary obstruction and UGIB amidst a supratherapeutic INR.
71-year-old male with history of atrial fibrillation on warfarin, presented with acute abdominal pain and jaundice. He was found to have elevated INR of 4.5, abnormal LFTs with total bilirubin of 5.7 mg/dL, AST 177 units/L & ALT 69 units/L. RUQ ultrasound showed cholelithiasis and features of cholecystitis along with “possible distal common bile duct density”. An ERCP, performed after correction of his INR, revealed hemobilia (Fig. 1a). Cholangiogram showed multiple small filling defects (Fig. 1b), but balloon sweeps yielded only blood clots without stones. The patient was then referred for cholecystectomy however, while awaiting surgery, he was admitted again for abdominal pain & melena with obstructive liver injury pattern. Labs indicated drop in HgB by 4 gm & INR of 9.6.
Given high suspicion for recurrent hemobilia, he underwent CT angiogram of abdomen which was negative for active bleeding and EGD was also negative. He then underwent laparoscopic-to-open cholecystectomy due to findings of dense adhesions of the omentum onto the gallbladder (GB). Additionally, he was also found to have localized perforation with possible early fistula to colon and duodenum that required oversewing of the colon, and Graham patch to the duodenum. A large irregular 3.2 cm gallstone was impacted in his GB which was removed. Pathology showed acute and chronic necrotizing xanthogranulomatous cholecystitis and no evidence of malignancy.
Discussion: The classic Quincke’s triad for hemobilia is described as RUQ pain, jaundice and UGIB however it is only present in 25-30% of the cases. Hemobilia is a rare but important cause of UGIB and can cause biliary obstruction. In a review study, M H Green et al. noted that most cases of hemobilia are iatrogenic (65%), with malignancy and trauma being important non-iatrogenic causes. A benign non iatrogenic cause like gallstone disease was noted in 5% of cases. In this case, it appeared that the large gallstone was causing inflammation of GB wall which provoked bleeding when patient reached supratherapeutic INR levels. Given the increasing number of patients on anticoagulation, biliary obstruction with concurrent melena should prompt consideration of hemobilia and its causes in the differential.
Figure: Figure 1a: Endoscopic image of ERCP with hemorrhagic contents coming out of ampulla. Figure 1b: Cholangiogram showing cannulation of the common bile duct with numerous filling defects.
Syed Hamza Sohail indicated no relevant financial relationships.
Bushra Zia indicated no relevant financial relationships.
Tiago Martins indicated no relevant financial relationships.
John Miller indicated no relevant financial relationships.
Syed Hamza Sohail, MD, Bushra Zia, MD, Tiago Martins, MD, John W. Miller, MD. P1155 - Recurrent Hemobilia Secondary to a Large Gallstone in the Setting of Systemic Anticoagulation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.