Hemobilia is a severe complication of biliary diseases and biliary surgery, as well as a common cause of upper gastrointestinal bleeding. It may originate from both intrahepatic and extrahepatic bile ducts, with intrahepatic bleeding being more frequent. Based on the etiology, hemobilia can be classified into the following types:
- Infectious;
- Traumatic;
- Neoplastic;
- Vascular.
The most common cause is biliary stone-associated infection. The close anatomical relationship between intrahepatic bile ducts and the branches of the hepatic artery and portal vein serves as the anatomical basis for hemobilia. The pathological basis often involves bile duct inflammation and rupture of the bile duct wall, leading to the formation of a fistula between the bile duct and adjacent blood vessels. Massive intrahepatic bile duct hemorrhage is mainly caused by an arterial-biliary fistula, while minor bleeding often results from erosion of the bile duct or gallbladder mucosa.
Clinical Manifestations
The clinical presentations of hemobilia vary depending on the underlying cause and the volume of bleeding. Minor bleeding may present as melena or positive occult blood fecal testing. Massive biliary bleeding typically manifests with a triad of symptoms:
- Biliary colic;
- Jaundice;
- Upper gastrointestinal bleeding (hematemesis or melena).
A distinctive feature of hemobilia is cyclical bleeding, occurring every 1–2 weeks. Patients with an intact sphincter of Oddi may experience spontaneous cessation of bleeding, but episodes may recur. During massive bleeding episodes, abrupt elevation of biliary pressure often leads to sphincter of Oddi spasms, with blood clots obstructing the bile ducts. This can result in biliary colic, followed by jaundice, and subsequently hematemesis or melena. Severe blood loss may cause hypovolemic shock.
Diagnosis
The diagnosis of hemobilia is generally not difficult when based on a medical history and the characteristic triad of symptoms with cyclical recurrence. However, differentiation from other causes of upper gastrointestinal bleeding is required. Duodenoscopy allows direct visualization of blood flowing from the duodenal papilla, confirming hemobilia and excluding other causes such as peptic ulcers or gastric cancer. Ultrasonography, CT, and MRI can help identify the underlying causes, such as biliary stones or hepatic tumors. Selective hepatic arteriography is highly valuable in diagnosing hemobilia and pinpointing the bleeding site. Biliary exploration remains the most direct diagnostic method. Using a choledochoscope, the bleeding site can often be clearly observed. During surgery, ultrasound can assist in identifying arterial-biliary fistulas by detecting vortex blood flow and can guide hepatic artery ligation on the affected side.
Treatment
Non-surgical treatment is preferred under the following conditions:
- Minimal bleeding;
- Absence of symptoms such as chills, fever, jaundice, or septic shock;
- Inability to tolerate surgery.
Measures include:
- Fluid resuscitation, blood transfusion, and restoration of blood volume to prevent and manage shock;
- Administration of sufficient and effective antibiotics to control infection;
- Use of hemostatic agents;
- Symptomatic management and supportive care;
For active bleeding, selective hepatic arteriography can be employed to locate the bleeding site, followed by super-selective hepatic artery embolization to achieve hemostasis.
Surgical intervention is indicated under the following circumstances:
- Recurrent massive bleeding, particularly when the bleeding episodes become shorter in interval and increase in volume;
- Severe biliary infections requiring surgical drainage;
- Massive hemobilia following biliary-enteric drainage surgery;
- Underlying diseases necessitating surgical treatment, such as hepatic tumors, vascular diseases of the liver, or liver abscess.
During surgery, identification of the bleeding source and etiology is essential. Procedures such as cholecystectomy, common bile duct exploration, T-tube drainage, hepatic artery ligation, or partial hepatectomy (lobectomy or segmentectomy) may be performed as required.