Case Report: Hemobilia of unusual manifestation and multiple localization

Introduction: It is considered to be infrequent that the source of upper gastrointestinal (GI) bleeding is the biliary tract. The classic form of hemobilia is manifested in abdominal pain, signs of jaundice and GI bleeding, which are not concomitant in all cases. The source of hemobilia may be the common bile duct, the gall bladder, the liver or the pancreas.

The presented Case is a 53-year-old female patient admitted to our department because of abdominal pain and jaundice. In the medical history liver cirrhosis due to chronic alcoholism is noted. On day 2 of hospitalization the signs of upper GI bleeding were observed. Upper panendoscopy revealed bleeding from the ampulla of Vater. The abdominal CT confirmed liver cirrhosis and cholelithiasis. Gall bladder tumor was also presumed but dilation of the biliary tract was not observed. No malignancy was revealed by MR cholangiography. The level of tumor markers was in the normal range. Endoscopic retrograde cholangiopancreatography examination was carried out, and actual bleeding was detected. During biliary lavage blood and blood clot passed through the ampulla of Vater. After a transient normalization of general condition, the signs of upper GI bleeding were again observed. Selective abdominal aortography was performed. From one of the terminal arteries of the cystic artery, the contrast medium leaked out into the gall bladder. Embolization was not carried out due to technical problems. Urgent laparoscopic cholecystectomy was performed in the surgical department. As a source of bleeding, angiovenous malformations were presumed in the muscle wall of the gall bladder by postoperative histological analysis. After an uneventful postoperative period, the patient was discharged. After a month the patient was readmitted to our department due to a new onset of biliary bleeding which was confirmed by upper panendoscopy. Selective abdominal arteriography was again performed. Contrast medium leakage was seen from the branch of the right hepatic artery in liver segments 6 and 7. Successful chemoembolization was carried out. A focal malignancy was also suspected in this region. Bleeding was not observed afterwards. After the normalization of coagulation parameters, the biopsy of the suspicious mass is planned.

Conclusion: This case is considered to be worthy of presentation owing to the rare and unusual cause of upper GI bleeding implied in it.