Upper Gastrointestinal Bleeding With Hemobilia Caused by Gallstones

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.

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.