Atraumatic hemobilia arising from a cirrhotic liver

Biliary hemorrhage may occur in a variety of clinical settings, but spontaneous hemobilia has not been reported from a cirrhotic liver. We describe a case of major hepatic hemobilia in a patient with cirrhosis and no history of trauma. A 50-year-old woman had abdominal pain, melena, and profound anemia. An extensive workup did not show the site of bleeding but did show a mass in the gallbladder. Cholecystectomy was performed, and at operation the patient was found to have cirrhosis and portal hypertension. The gallbladder "mass" was simply an organized clot, and hemorrhage recurred postoperatively. On reoperation, bleeding from the ampulla of Vater was observed, confirming the diagnosis of hemobilia. She was treated with angiographic interruption of hepatic arterial flow, at which time bleeding ceased. Her total transfusion requirements included 46 units of blood. Through 16 months of follow-up the patient has had no recurrent bleeding and no evidence of encephalopathy. This case demonstrates that spontaneous hemobilia may indeed arise from a cirrhotic liver. Proximal interruption of arterial flow is usually not recommended for hemobilia, especially in the presence of portal hypertension and cirrhosis, but may be life-saving in selected patients.