Advertisement

Upper Gastrointestinal Bleeding With Hemobilia Caused by Gallstones

  • Chia-Wen Chang
    Affiliations
    Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
    Search for articles by this author
  • Yen-Hung Wu
    Affiliations
    Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
    Search for articles by this author
  • Hsin-Liang Liu
    Correspondence
    Reprint Address: Hsin-Liang Liu, md, Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Shichuan 1st Road, Kaohsiung 80708, Taiwan
    Affiliations
    Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
    Search for articles by this author

      Abstract

      Background

      Hemobilia refers to bleeding in the biliary tract, commonly due to iatrogenic, traumatic, and neoplastic causes. It is a rare source of upper gastrointestinal hemorrhage, but it can be severe and fatal. However, gallstones account for 5%–15% of hemobilia cases.

      Case Report

      A 60-year-old woman with diabetes mellitus and chronic kidney disease visited the emergency department with complaints of epigastric pain and vomiting of coffee ground–like content for 2 days. Physical examination revealed epigastric tenderness and hyperactive bowel sounds. Laboratory tests showed anemia with a hemoglobin count of 10.7 mg/dL and elevated liver function tests with total and direct bilirubin levels of 3.6 mg/dL and 2.5 mg/dL, respectively. Panendoscopy showed oozing of coffee ground–like material at the orifice of the ampulla of Vater and second portion of the duodenum, leading to suspicion of hemobilia. After admission, endoscopic retrograde cholangiopancreatography revealed common bile duct (CBD) dilatation with choledocholithiasis, biliary sludge, and filling defect at the middle section of the CBD. Endoscopic sphincterotomy with balloon lithotripsy was performed. After biliary decompression and broad-spectrum antibiotic administration, abdominal pain was relieved, and liver enzyme and total bilirubin levels improved. Symptoms of hemobilia depend on the bleeding rate and presence of bile duct obstructions due to clots. Minor and slow bleeding tend to form clots and cause biliary obstruction.

      Why Should an Emergency Physician Be Aware of This?

      Although minor hemobilia may remain asymptomatic and tends to resolve spontaneously, the cause of hemobilia must be corrected to prevent recurrent bleeding or obstruction.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Berry R.
        • Han J.Y.
        • Kardashian A.A.
        • LaRusso N.F.
        • Tabibian J.H.
        Hemobilia: etiology, diagnosis, and treatment.
        Liver Res. 2018; 2: 200-208
        • Cathcart S.
        • Birk J.W.
        • Tadros M.
        • Schuster M.
        Hemobilia: an uncommon but notable cause of upper gastrointestinal bleeding.
        J Clin Gastroenterol. 2017; 51: 796-804
        • Kim K.H.
        • Kim T.N.
        Etiology, clinical features, and endoscopic management of hemobilia: a retrospective analysis of 37 cases.
        Korean J Gastroenterol. 2012; 59: 296-302
        • Sandblom P.
        • Mirkovitch V.
        Minor hemobilia. Clinical significance and pathophysiological background.
        Ann Surg. 1979; 190: 254-264
        • Keizman D.
        • Ish-Shalom M.
        • Konikoff F.M.
        The clinical significance of bile duct sludge: is it different from bile duct stones?.
        Surg Endosc. 2007; 21: 769-773
        • Luu M.B.
        • Deziel D.J.
        Unusual complications of gallstones.
        Surg Clin N Am. 2014; 94: 377-394
        • Shimoji H.
        • Shiraishi M.
        • Hiroyasu S.
        • Isa T.
        • Kusano T.
        • Muto Y.
        Common bile duct blood clot: an unusual cause of ductal filling defects for calculi.
        J Gastroenterol. 1999; 34: 420-423