Alternative names
Haemobilia Haemorrhage in bile Hematobilia Hemobilia Hemobilia (disorder) Hemorrhage in bile

Implies bleeding into biliary tree

Biliary tree

The biliary tract is the common anatomical term for the path by which bile is secreted by the liver then transported to the first part of the small intestine, also known as the duodenum...

. Can present as acute upper gastrointestinal(UGI) bleeding. It should be considered in upper abdominal pain presenting with UGI bleeding especially when there is a history of liver injury or instrumentation.

• First recorded in 1654 by Francis Glisson, a Cambridge
  University of Cambridge
  The University of Cambridge is a public research university located in Cambridge, United Kingdom. It is the second-oldest university in both the United Kingdom and the English-speaking world , and the seventh-oldest globally...
  
   professor.
• Haemobilia occurs when there is a fistula
  Fistula
  In medicine, a fistula is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons.-Locations:Fistulas can develop in various parts of the...
  
   between a vessel of the splanchnic
  Splanchnic
  Splanchnic, from a Greek word spēn, meaning organ, usually used to describe visceral organs.More specifically, it can also refer to:* An adjective describing the intestines* Splanchnic nerves* Splanchnic mesoderm...
  
   circulation and the intrahepatic or extrahepatic biliary system.

Causes

• Trauma
  Physical trauma
  Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
  
  , accidental or iatrogenic e.g. due to procedures like cholecystectomy
  Cholecystectomy
  Cholecystectomy is the surgical removal of the gallbladder. It is the most common method for treating symptomatic gallstones. Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.-Open surgery:A...
  
  
• Instrumentation e.g. after ERCP
• Gallstone
  Gallstone
  A gallstone is a crystalline concretion formed within the gallbladder by accretion of bile components. These calculi are formed in the gallbladder, but may pass distally into other parts of the biliary tract such as the cystic duct, common bile duct, pancreatic duct, or the ampulla of...
  
  
• Inflammatory
  Inflammation
  Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
  
   conditions ranging from ascariasis
  Ascariasis
  Ascariasis is a human disease caused by the parasitic roundworm Ascaris lumbricoides. Perhaps as many as one quarter of the world's people are infected, with rates of 45% in Latin America and 95% in parts of Africa. Ascariasis is particularly prevalent in tropical regions and in areas of poor...
  
   to PAN
  Polyarteritis nodosa
  Polyarteritis nodosa is a vasculitis of medium & small-sized arteries, which become swollen and damaged from attack by rogue immune cells. Polyarteritis nodosa is also called Kussmaul disease or Kussmaul-Maier disease...
  
  
• Vascular malformation
• Tumor
  Tumor
  A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
  
  
• Coagulopathy

Clinical feature

"Quinke's" triad of upper abdominal pain, upper gastrointestinal haemorrhage

Upper gastrointestinal bleeding

Upper gastrointestinal bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.Upper GI bleeds are considered...

 and jaundice

Jaundice

Jaundice is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia . This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid...

 is classical but only present in 22% cases.

It can be immediately life threatening in major bleeding. However in minor haemobilia patient is haemodynamically stable despite significant blood loss being apparent.

Investigation

Combination of OGD

OGD

OGD is a three-letter initialism with the following meanings:* Open Government Data * The British medical abbreviation for oesophagogastroduodenoscopy, a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum.* The IATA airport code for...

, CT scan and angiography depending on clinical situation, bearing in mind that haemobilia may present many days after injury. Cholangiography

Cholangiography

Cholangiography is the imaging of the bile duct by x-rays. There are at least two kinds of cholangiography:* percutaneous transhepatic cholangiography : Examination of liver and bile ducts by x-rays...

 is performed if there is a percutaneous access or if ERCP is undertaken.

Management

Most bleeding from instrumentation are minor and would settle spontaneously.

When indicated, management is directed towards stopping bleeding and relieving obstruction if present, which is achieved either by surgical ligation of hepatic artery or by endoscopic embolisation. Endoscopic trans-arterial embolisation (TAE) is preferred initially because of high success rate and less complication. TAE involves the selective catheterization of a hepatic artery followed by embolic occlusion. Surgery is indicated when TAE has failed or sepsis present in biliary tree or drainage has failed.