A 45-year-old man with chronic pancreatitis underwent transjugular liver biopsy for the evaluation of esophageal varices and ascites. A few days after the liver biopsy, he developed new-onset jaundice and melena. Computed tomography of the abdomen showed the presence of ascites, a liver with cirrhotic morphology, and a biliary tree that appeared normal. Upper endoscopy for the evaluation of the melena showed fresh blood in the duodenum without a clear source of bleeding. An evaluation with a duodenoscope (a side-view endoscope) showed slow oozing of blood from the ampulla (Fig. FigA). Endoscopic retrograde cholangiopancreatography (ERCP) revealed a large filling defect occupying the entire extrahepatic biliary tree from the confluence to the ampulla (Fig. FigB). Sweeps of the bile duct yielded a large number of blood clots. Cholangioscopy with a prototype video choledochoscope (CHF-Y0002, Olympus, Japan) showed slow oozing of blood into the left hepatic duct from a more proximal source (Fig. FigC). A fully covered metallic stent (WallFlex biliary stent, Boston Scientific, Natick, MA) was placed in the bile duct to ensure biliary drainage while the patient waited for the final treatment of embolization of the bleeding vessel. Subsequent angiography, however, did not show any bleeding (Fig. FigD).

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Figure  . (A) Oozing of blood from the ampulla. (B) Filling defect from the confluence to the ampulla. (C) Slow oozing of blood into the left hepatic duct. (D) No bleeding on angiography.

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Hemobilia is an uncommon entity but is part of the differential diagnosis of upper gastrointestinal bleeding. It occurs when there is a fistula between a vessel of the splanchnic circulation and the intrahepatic or extrahepatic biliary system. The causes of hemobilia are numerous. Trauma was the most frequent cause in earlier years.1 More recently, however, most cases are due to medical procedures such as the creation of transhepatic biliary access, liver biopsy, cholecystectomy, and therapeutic ERCP.2 Other causes include gallstones, infections, malignancies, and vascular abnormalities of the hepatobiliary system.

Jaundice as a result of hemobilia is uncommon. It has been suggested that bile has thrombolytic activity, and for clots to form, the bleeding has to be slow. With slow hemorrhaging, blood and bile do not mix because of their different specific gravities and surface tensions, which make clot formation possible.2

The treatment of jaundice associated with hemobilia usually requires a dual-track strategy: control of bleeding and relief of jaundice. Bleeding stops in approximately half of the cases with just supportive therapy. Embolization of the bleeding source is required if bleeding is persistent or severe. Relief of jaundice is achieved by ERCP. In selected cases, cholangioscopy at the time of ERCP can aid in the determination of the extent of clot formation and the localization of the bleeding source.3-5


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  2. References
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    Goodnight JE Jr, Blaisdell FW. Hemobilia. Surg Clin North Am 1981; 61: 973979.
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    Green MH, Duell RM, Johnson CD, Jamieson NV. Haemobilia. Br J Surg 2001; 88: 773786.
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    Hayashi S, Baba Y, Ueno K, Nakajo M. Small arteriovenous malformation of the common bile duct causing hemobilia in a patient with hereditary hemorrhagic telangiectasia. Cardiovasc Intervent Radiol 2008; 31( Suppl 2): S131S134.
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    Prasad GA, Abraham SC, Baron TH, Topazian MD. Hemobilia caused by cytomegalovirus cholangiopathy. Am J Gastroenterol 2005; 100: 25922595.
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    Siddique I, Galati J, Ankoma-Sey V, Wood RP, Ozaki C, Monsour H, et al. The role of choledochoscopy in the diagnosis and management of biliary tract diseases. Gastrointest Endosc 1999; 50: 6773.