Haemobilia

Overview
Implies bleeding into biliary tree. 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 professor.
 * Haemobilia occurs when there is a fistula between a vessel of the splanchnic circulation and the intrahepatic or extrahepatic biliary system.

Causes

 * Trauma, accidental or iatrogenic e.g. due to procedures like cholecystectomy
 * Instrumentation e.g. after ERCP
 * Gallstone
 * Inflammatory conditions ranging from ascariasis to PAN
 * Vascular malformation
 * Tumor
 * Coagulopathy

Clinical feature
Triad of upper abdominal pain, upper gastrointestinal haemorrhage and jaundice 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, CT scan and angiography depending on clinical situation, bearing in mind that haemobilia may present many days after injury. Cholengiography 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.