Hemobilia, in patients with the diagnosis of polyarteritis nodosa, is rare at clinical presentation and has a grave prognosis. We describe a case of massive hemobilia, due to aneurysmal rupture, in a patient with polyarteritis nodosa. A 39-year-old man was admitted to the hospital with upper abdominal pain. The patient had a history of partial small bowel resection, for intestinal infarction, about 5 years prior to this presentation. Abdominal computed tomography demonstrated multiple high attenuation areas in the bile duct and gallbladder. Hemobilia with blood seepage was visualized on endoscopic retrograde cholangiopancreatography; this bleeding stopped spontaneously. The following day, the patient developed a massive gastrointestinal bleed with resultant hypovolemic shock. Emergent hepatic angiogram revealed multiple microaneurysms; a communication was identified between a branch of the left hepatic artery and the bile duct. Hepatic arterial embolization was successfully performed. The underlying disease, polyarteritis nodosa, was managed with prednisolone and cyclophosphamide.
Rupture/*complications ; Polyarteritis Nodosa/*physiopathology ; Male ; Humans ; Hepatic Artery/*pathology ; Hemobilia/diagnosis/*etiology ; *Embolization, Therapeutic ; Aneurysm, Ruptured/*complications/therapy ; Adult

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.
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

BACKGROUND/AIMS: Hemobilia is a rare cause of upper gastrointestinal bleeding. Endoscopic retrograde cholangiopancreaticography (ERCP) is considered to be an excellent diagnostic and treatment modality. Thirty-seven cases of hemobilia with different underlying pathologies were analyzed to illustrate clinical features and to evaluate the role of endoscopic management. METHODS: A total of 37 patients (26 men and 11 women; mean age, 66.2+/-15.3 years) who were confirmed to have hemobilia by ERCP in a single center from 2000 to 2010 were reviewed retrospectively. Patients with iatrogenic causes of hemobilia were excluded in this study. RESULTS: The causes of hemobilia were hepatocellular carcinoma in 14, bile duct and gallbladder malignancies in 12, common bile duct stones with cholangitis in 4, acute cholecystitis in 4, and pancreatic cancer in 2 patients. The clinical features of hemobilia were jaundice (89.2%), abdominal pain (78.4%), and melena (13.5%). The cholangiographic findings of hemobilia were amorphous filling defects in 15, tubular filling defects in 6, and cast-like filling defects in 6 patients. Endoscopic management included endoscopic nasobiliary drainage in 26 patients and endoscopic retrograde biliary drainage in 7 patients. Biliary obstruction caused by hemobilia was successfully treated with endoscopic biliary drainages in most cases. CONCLUSIONS: The most common non-iatrogenic causes of hemobilia were hepatobiliary malignancies, and the majority of patients presented with jaundice and abdominal pain. Endoscopic biliary drainage is recommended as the initial management to control biliary obstruction.
Abdominal Pain/etiology ; Adult ; Aged ; Aged, 80 and over ; Bile Duct Neoplasms/complications ; Carcinoma, Hepatocellular/complications ; Cholangiopancreatography, Endoscopic Retrograde ; Cholecystectomy ; Cholecystitis/complications ; Drainage ; Female ; Gallstones/complications ; Hemobilia/*diagnosis/etiology/therapy ; Humans ; Jaundice/etiology ; Liver Neoplasms/complications ; Male ; Middle Aged ; Pancreatic Neoplasms/complications ; Retrospective Studies