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Hemobilia: A Rare Presentation of Acute Cholecystitis
Image of the Month Hemobilia: A Rare Presentation of Acute Cholecystitis DILKA I. GONZALEZ– ORTIZ, DORIS H. TORO, and WANDA VEGA Gastroenterology and Radiology Departments, VA Caribbean Healthcare System, San Juan, Puerto Rico
A
75-year-old man was evaluated at the VA Caribbean Healthcare System’s emergency room on August 2006 after he was brought in by his son. The patient was found at home lying on the floor, disoriented and confused. At the evaluation, the patient complained of stabbing retrosternal chest pain that lasted about 30 minutes. The pain did not irradiate but was associated to shortness of breath. The patient also referred to marked progressive weakness for the past few weeks and an episode of loss of con-
sciousness about 2 weeks before. He denied previous episodes of chest pain, nausea, vomiting, diarrhea, melena, or hematochezia. He also denied alcohol use or over-thecounter medications. The patient had a long-standing his-
© 2008 by the AGA Institute
1542-3565/08/$34.00 doi:10.1016/j.cgh.2008.06.015 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:e36 – e37
October 2008
tory of hypertension, hyperlipidemia, hypothyroidism, and prostatic carcinoma. His vital signs at admission showed a blood pressure of 152/72 mm Hg, a temperature of 97°F, a pulse rate of 68 bpm, and a respiratory rate of 20/min. The patient was alert and oriented only to person and place. His speech was slow and appeared somnolent and confused. The physical examination was essentially negative except for the presence of pain on palpation in the right upper quadrant and stools strongly positive for occult blood. There was no hepatosplenomegaly, spider angiomas, or signs of chronic liver disease. Laboratory tests at admission were relevant for leukocytosis of 15,000 with immature forms and hemoglobin of 7.2 g/dL. In addition, there was evidence of altered liver enzymes with an alanine aminotransferase level of 630 U/L, an aspartate aminotransferase level of 1360 U/L, an alkaline phosphatase level of 306 U/L, and a minimally increased bilirubin level of 1.58 mg/dL. Additional laboratory results revealed a thyroid-stimulating hormone level of 98.3 uIU/mL. Cardiac enzyme levels and an electrocardiogram were negative for an acute ischemic event. Aggressive intravenous hydration and empiric antibiotic therapy were started. Thyroid replacement was provided as recommended by the endocrinology team. An abdominal sonogram was performed the day after admission and showed abnormally thickened gallbladder walls and findings suggestive of cholelithiasis. Additional evaluation with a computerized tomography (CT) scan was recommended to try to distinguish between an infiltrative neoplastic or an inflammatory process. The abdominal CT scan (Figure A) showed a distended gallbladder and its lumen filled with heterogeneous and intermediate-density contents, which did not show contrast enhancement. The gallbladder wall was diffusely enhancing with a small area of active contrast extravasation into the lumen. In addition, marked soft-tissue stranding and increased density of the pericholecystic fat was observed. The radiologist interpreted the described findings as a complicated cholecystitis with hemobilia. After the CT scan, the patient became unstable, showing persistent hypotension that required aggressive resuscitation including blood transfusions, vasopressors, and transfer to the intensive care unit. Based on the CT findings of suspected
IMAGE OF THE MONTH
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hemobilia, the interventional radiology team was consulted to consider selective embolization. A visceral angiography that included the hepatic, splenic, and superior mesenteric artery, and then subselective angiography of the proper hepatic, right hepatic, and cystic duct identified the area of extravasation at one branch of the cystic artery (Figure B). The cystic artery was catheterized with a 3F microcatheter system and successfully was embolized proximally with three 2- to 20-mm, 0.018 inches complex platinum coils. The flow of the hepatic artery was preserved (Figure C). There were no subsequent bleeding episodes and after a very complicated inpatient stay, the patient was discharged home 2.5 months later. Hemobilia is a rare cause of gastrointestinal bleeding, representing less than 1% of all episodes of acute gastrointestinal bleeding. Bleeding from the hepatobiliary tree usually is associated to trauma to the liver and biliary tree either accidental or secondary to surgical or endoscopic procedures. The most common procedures that have been associated to this complication are as follows: percutaneous and transjugular liver biopsy, percutaneous transhepatic cholangiogram, cholecystectomy (either open or laparoscopic), endoscopic biliary biopsies and/or trauma during endoscopic retrograde cholangiopancreatography, after transjugular intrahepatic portosystemic shunting, or angioembolization of liver lesions. Other less common causes of hemobilia are gallstones, cholecystitis, hepatic or bile duct tumors, intrahepatic stents, inflammatory lesions such as hepatic abscesses, and hepatic artery aneurysms. This case shows an unusual presentation of acute cholecystitis that was evident during an abdominal CT scan that showed active bleeding from the gallbladder wall. Only a few cases have been reported in the medical literature associating acute cholecystitis and hemobilia, almost all related to previous surgical or invasive procedures of the biliary tract. Diagnosis of hemobilia in this patient was not clinically evident at the time of admission but was identified rapidly and managed effectively by subselective cystic artery embolization. The association of gastrointestinal bleeding and altered liver function test results with or without biliary obstruction should alert the physician to strongly consider hemobilia in the differential diagnosis.
A
75-year-old man was evaluated at the VA Caribbean Healthcare System’s emergency room on August 2006 after he was brought in by his son. The patient was found at home lying on the floor, disoriented and confused. At the evaluation, the patient complained of stabbing retrosternal chest pain that lasted about 30 minutes. The pain did not irradiate but was associated to shortness of breath. The patient also referred to marked progressive weakness for the past few weeks and an episode of loss of con-
sciousness about 2 weeks before. He denied previous episodes of chest pain, nausea, vomiting, diarrhea, melena, or hematochezia. He also denied alcohol use or over-thecounter medications. The patient had a long-standing his-
© 2008 by the AGA Institute
1542-3565/08/$34.00 doi:10.1016/j.cgh.2008.06.015 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:e36 – e37
October 2008
tory of hypertension, hyperlipidemia, hypothyroidism, and prostatic carcinoma. His vital signs at admission showed a blood pressure of 152/72 mm Hg, a temperature of 97°F, a pulse rate of 68 bpm, and a respiratory rate of 20/min. The patient was alert and oriented only to person and place. His speech was slow and appeared somnolent and confused. The physical examination was essentially negative except for the presence of pain on palpation in the right upper quadrant and stools strongly positive for occult blood. There was no hepatosplenomegaly, spider angiomas, or signs of chronic liver disease. Laboratory tests at admission were relevant for leukocytosis of 15,000 with immature forms and hemoglobin of 7.2 g/dL. In addition, there was evidence of altered liver enzymes with an alanine aminotransferase level of 630 U/L, an aspartate aminotransferase level of 1360 U/L, an alkaline phosphatase level of 306 U/L, and a minimally increased bilirubin level of 1.58 mg/dL. Additional laboratory results revealed a thyroid-stimulating hormone level of 98.3 uIU/mL. Cardiac enzyme levels and an electrocardiogram were negative for an acute ischemic event. Aggressive intravenous hydration and empiric antibiotic therapy were started. Thyroid replacement was provided as recommended by the endocrinology team. An abdominal sonogram was performed the day after admission and showed abnormally thickened gallbladder walls and findings suggestive of cholelithiasis. Additional evaluation with a computerized tomography (CT) scan was recommended to try to distinguish between an infiltrative neoplastic or an inflammatory process. The abdominal CT scan (Figure A) showed a distended gallbladder and its lumen filled with heterogeneous and intermediate-density contents, which did not show contrast enhancement. The gallbladder wall was diffusely enhancing with a small area of active contrast extravasation into the lumen. In addition, marked soft-tissue stranding and increased density of the pericholecystic fat was observed. The radiologist interpreted the described findings as a complicated cholecystitis with hemobilia. After the CT scan, the patient became unstable, showing persistent hypotension that required aggressive resuscitation including blood transfusions, vasopressors, and transfer to the intensive care unit. Based on the CT findings of suspected
IMAGE OF THE MONTH
e37
hemobilia, the interventional radiology team was consulted to consider selective embolization. A visceral angiography that included the hepatic, splenic, and superior mesenteric artery, and then subselective angiography of the proper hepatic, right hepatic, and cystic duct identified the area of extravasation at one branch of the cystic artery (Figure B). The cystic artery was catheterized with a 3F microcatheter system and successfully was embolized proximally with three 2- to 20-mm, 0.018 inches complex platinum coils. The flow of the hepatic artery was preserved (Figure C). There were no subsequent bleeding episodes and after a very complicated inpatient stay, the patient was discharged home 2.5 months later. Hemobilia is a rare cause of gastrointestinal bleeding, representing less than 1% of all episodes of acute gastrointestinal bleeding. Bleeding from the hepatobiliary tree usually is associated to trauma to the liver and biliary tree either accidental or secondary to surgical or endoscopic procedures. The most common procedures that have been associated to this complication are as follows: percutaneous and transjugular liver biopsy, percutaneous transhepatic cholangiogram, cholecystectomy (either open or laparoscopic), endoscopic biliary biopsies and/or trauma during endoscopic retrograde cholangiopancreatography, after transjugular intrahepatic portosystemic shunting, or angioembolization of liver lesions. Other less common causes of hemobilia are gallstones, cholecystitis, hepatic or bile duct tumors, intrahepatic stents, inflammatory lesions such as hepatic abscesses, and hepatic artery aneurysms. This case shows an unusual presentation of acute cholecystitis that was evident during an abdominal CT scan that showed active bleeding from the gallbladder wall. Only a few cases have been reported in the medical literature associating acute cholecystitis and hemobilia, almost all related to previous surgical or invasive procedures of the biliary tract. Diagnosis of hemobilia in this patient was not clinically evident at the time of admission but was identified rapidly and managed effectively by subselective cystic artery embolization. The association of gastrointestinal bleeding and altered liver function test results with or without biliary obstruction should alert the physician to strongly consider hemobilia in the differential diagnosis.