Korean J Gastroenterol.  2013 Jan;61(1):46-49. 10.4166/kjg.2013.61.1.46.

Massive Bleeding Hemobilia Occurred in Patient with Hepatocellular Carcinoma

• Lee KE
• Kim CW
• Kim MJ
• Park J
• Cho GM
• Jang JW
• Lee YS
• Lee CD

• KMID: 1775787
• DOI: http://doi.org/10.4166/kjg.2013.61.1.46

Abstract

Massive bleeding hemobilia occurs rarely in patients with hepatocellular carcinoma (HCC) without any invasive procedure. Upper gastrointestinal bleeding in patient with cirrhosis and abdominal pain with progressive jaundice in patient with HCC were usually thought as variceal bleeding and HCC progression respectively. We experienced recently massive bleeding hemobilia in patient with HCC who was a 73-year old man and showed sudden abdominal pain, jaundice and hematochezia. He had alcoholic cirrhosis and history of variceal bleeding. One year ago, he was diagnosed as HCC and treated with transarterial chemoembolization periodically. Sudden right upper abdominal pain occurred then subsided with onset of hemotochezia. Computed tomography showed bile duct thrombosis spreading in the intrahepatic and extrahepatic ducts, while an ampulla of vater bleeding was observed during duodenoscopy. Hemobilia could be one of the causes of massive bleeding in patients with cirrhosis and HCC especially when they had sudden abdominal pain and abrupt elevation of bilirubin.

Keyword

Hemobilia; Carcinoma, hepatocellular; Gastrointestinal hemorrhage; Cholestasis

MeSH Terms

Aged
Bile Ducts, Extrahepatic
Bile Ducts, Intrahepatic
Bilirubin/analysis
Carcinoma, Hepatocellular/complications/*diagnosis/therapy
Duodenoscopy
Embolization, Therapeutic
Hemobilia/*etiology
Humans
Jaundice/etiology
Liver Cirrhosis/complications
Liver Neoplasms/complications/*diagnosis/therapy
Male
Severity of Illness Index
Thrombosis/diagnosis
Tomography, X-Ray Computed
Bilirubin

Figure

• 

  Fig. 1. Abdominal CT scan showed intrahepatic and extrahepatic bile duct thrombosis in the patients with hepatocellular carcinoma and cirrhosis. (A) Contrast enhanced axial CT scans showed the dilated intrahepatic bile duct filled with intraluminal hyperattenuated material, bile duct thrombus (arrows). (B) Contrast enhanced coronal CT scans showed the dilated extahepatic bile duct filled with intraluminal hyperattenuated materials, bile duct thrombus (arrows). (C) Contrast enhanced axial CT scan during arterial phase showed multiple arterial enhancing nodules near the bile duct (arrows).

• 

  Fig. 2. Bleeding from ampulla of Vater was observed during duodenoscopy.

Reference

References

1. Dallal HJ, Palmer KR. ABC of the upper gastrointestinal tract: Upper gastrointestinal haemorrhage. BMJ. 2001; 323:1115–1117.

2. Green MH, Duell RM, Johnson CD, Jamieson NV. Haemobilia. Br J Surg. 2001; 88:773–786.

3. Merrell SW, Schneider PD. Hemobilia–evolution of current diagnosis and treatment. West J Med. 1991; 155:621–625.

4. Sandblom P. Hemorrhage into the biliary tract following trauma; traumatic hemobilia. Surgery. 1948; 24:571–586.

5. Kojiro M, Kawabata K, Kawano Y, Shirai F, Takemoto N, Nakashima T. Hepatocellular carcinoma presenting as intrabile duct tumor growth: a clinicopathologic study of 24 cases. Cancer. 1982; 49:2144–2147.

6. Shibata T, Hattori K, Hirai H, Fujii H, Aoyama T, Seuhiro S. Rectus abdominis myocutaneous flap after unsuccessful delayed ster-nal closure. Ann Thorac Surg. 2003; 76:956–958.

7. Afroudakis A, Bhuta SM, Ranganath KA, Kaplowitz N. Obstructive jaundice caused by hepatocellular carcinoma. Report of three cases. Am J Dig Dis. 1978; 23:609–617.

8. Cajot O, Descamps C, Navez B, Lacremans D, Druez P. Hemobilia disclosing very small hepatocellular carcinoma ruptured into the biliary ducts. Gastroenterol Clin Biol. 1997; 21:426–429.

9. Casagrande A, Liscidini P, Pepoli R. Obstructive icterus caused by a biliary thrombus due to hemobilia caused by a hepa-tocarcinoma. Case observation. Minerva Chir. 1985; 40:571–576.

10. Cho SJ, Ryu JK, Myung SJ, et al. A case of hepatocellular carcinoma invading intrahepatic duct complicated by hemobilia. Korean J Gastrointest Endosc. 2005; 31:278–281.

11. Contractor QQ, Boujemla M, ul Haque I. Hepatoma cast obstructing common bile duct: not always a terminal event. Indian J Gastroenterol. 1997; 16:121.

12. Hamy A, Paineau J, Savigny B, et al. Tumoral rupture in the intrahepatic biliary tracts: a rare manifestation of hepatocellular carcinoma. J Chir (Paris). 1997; 134:128–132.

13. Hsu CL, Wang CH, Chen RJ, Chen TC. Hepatocellular carcinoma presenting as jaundice, hemobilia, and acute pancreatitis: a case report. Changgeng Yi Xue Za Zhi. 1998; 21:232–236.

14. Johns WA, Zimmerman A. Biliary obstruction due to hemobilia caused by liver cell carcinoma. Ann Surg. 1961; 153:706–710.

15. Kitagawa K, Yamakado K, Nakatsuka A, et al. Selective transcatheter hepatic arterial chemoembolization for hemobilia from hepatocellular carcinoma: report of three cases. J Vasc Interv Radiol. 1999; 10:1357–1360.

16. Shibata T, Sagoh T, Maetani Y, et al. Transcatheter arterial embolization for bleeding from bile duct tumor thrombi of hepatocellular carcinoma. Hepatogastroenterology. 2003; 50:1119–1123.

17. Takao Y, Yoshida H, Mamada Y, Taniai N, Bando K, Tajiri T. Transcatheter hepatic arterial embolization followed by microwave ablation for hemobilia from hepatocellular carcinoma. J Nippon Med Sch. 2008; 75:284–288.

18. Qin LX, Tang ZY. Hepatocellular carcinoma with obstructive jaundice: diagnosis, treatment and prognosis. World J Gastroenterol. 2003; 9:385–391.

19. Xiangji L, Weifeng T, Bin Y, et al. Surgery of hepatocellular carcinoma complicated with cancer thrombi in bile duct: efficacy for criteria for different therapy modalities. Langenbecks Arch Surg. 2009; 394:1033–1039.

20. Srivastava DN, Sharma S, Pal S, et al. Transcatheter arterial embolization in the management of hemobilia. Abdom Imaging. 2006; 31:439–448.