[Endoscopic diagnosis and treatment of non-traumatic bilhemia. A case report]

Biliovascular fistulas are abnormal communications with two types of clinical manifestations depending on type of flow in fistulous tract: 1) hemorrhage into biliary tract known as hemobilia, or 2) bile into bloodstream, known as bilhemia. Historically, this complication has been treated with surgery; however, technological progress at present allows treatment with intervention techniques without surgery being mandatory. In 1975, Clemens and Wittrin introduced the term bilhemia, a rare complication of hepatic damage producing excessively high levels of serum bilirubin and moderate rise of hepatic enzymes secondary to post-traumatic intrahepatic biliovenous fistula. Although this pathology is rare, it is considered dangerous; of 50 patients reported in the literature, 25 died due to this problem. The main purpose of treatment is to release tract obstruction by endoscopic sphincterotomy of Vater's papilla or, if the process is localized in proximal areas of biliary tract, through percutaneous biliary drainage or preferably nasobiliary drainage with continuous suction. This procedure can at least produce temporary relief and occasionally fistula closure. A longer effect can be achieved with biliary stent placement. We describe what is, to our knowledge, the first case of diagnosis and successful treatment of non-traumatic bilhemia with endoscopic sphincterotomy and nasobiliary catheter placement.