Massive hemobilia

Massive hemobilia is a relatively rare, but potentially life-threatening cause of upper gastrointestinal hemorrhage. We report our experiences in the treatment of 15 cases of massive hemobilia with different underlying pathologies.

Massive hemobilia is defined as a patient with blood discharge from the biliary tree and requiring whole blood transfusion for at least 4 u (1 u = 250 cc). Fifteen such patients were collected during an 8.5-year period (from January 1986 to July 1994), and the clinical courses of these patients were retrospectively reviewed.

Among these 15 patients, 11 were males and 4 were females. Age distribution was from 33 to 78 years old. Mean age was 59.7 years. The cause of hemobilia included: percutaneous transhepatic biliary drainage in 7 patients, surgical trauma in 3, choledochoscopic extraction of biliary calculi in 1, pancreatic cancer in 1, radiotherapy for cholangiocarcinoma in 1, after operation for biliary lithiasis in 1, and rupture of the pseudoaneurysm in 1. In 11 patients, hemobilia was first noted by bleeding from percutaneous transhepatic biliary drainage tube (n = 10) or T-tube (n = 1). Three patients had hemobilia during choledocholithotomy. The other one was diagnosed by choledochoscopy. Treatment included pitressin infusion from angiographic catheter in one patient, transarterial embolization in 1, hepatic artery ligation in 1, hepatic artery ligation and transarterial embolization in 1, choledochotomy or choledocholithotomy in 2, and blood transfusion only in 9. Two of the four mortality cases had underlying malignancy.

The most common cause of massive hemobilia was percutaneous transhepatic biliary drainage procedures. Eight cases were successfully treated with blood transfusion only. Transarterial embolization, hepatic artery ligation and open drainage were effective non-surgical and surgical procedures, but the former two procedures might not be successful if sudden and severe hemobilia developed, or when an aberrant hepatic artery existed. Main hepatic artery had better been isolated before removal of the percutaneous transhepatic biliary drainage tube during operation.