Hemobilia caused by a ruptured hepatic cyst: a case report.
BACKGROUND
Hemobilia is a rare cause of upper gastrointestinal bleeding. More than 50% of hemobilia cases are related to iatrogenic trauma from hepatobiliary procedures, and needle biopsy of the liver represents the most common cause. A minority of hemobilia cases are due to hepatobiliary disorders such as cholangitis, hepatobiliary cancers, choledocholithiasis, and vascular abnormalities in the liver. The classic presentation of hemobilia is the triad of right upper quadrant (biliary) pain, obstructive jaundice, and upper gastrointestinal bleeding. We report a rare case of hemobilia caused by a spontaneous hepatic cyst rupture, where our patient presented without the classical symptoms, in the absence of therapeutic or pathological coagulopathy, and in the absence of spontaneous or iatrogenic trauma.


METHODS
A 91-year-old African-American woman was referred to our out-patient gastroenterology clinic for evaluation of mild epigastric pain and intermittent melena. An abdominal computed tomography scan was remarkable for multiple hepatic cysts. Esophagogastroduodenoscopy revealed multiple blood clots at the ampulla of Vater. Endoscopic retrograde cholangiopancreatography showed a single 18 mm-sized filling defect in the common hepatic duct wall at the junction of the right and left hepatic duct, adjacent to one of the hepatic cysts. The ruptured hepatic cyst communicated to the bile ducts and was the cause of hemobilia with an atypical clinical presentation.


CONCLUSIONS
Hemobilia is an infrequent cause of upper gastrointestinal bleeding and rarely occurs due to hepatic cyst rupture. To the best of our knowledge, this is only the second case report in the literature that describes hemobilia due to hepatic cyst rupture. However, it is the first case in the literature of hemobilia due to hepatic cyst rupture in the absence of iatrogenic or spontaneous trauma, and in the absence of a spontaneous or pathological coagulopathy.
Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Sinai Hospital, Baltimore, MD, USA. vsenadhi@hotmail.com.
Viplove
V
Senadhi
Deepika
D
Arora
Manish
M
Arora
Sudhir
S
Dutta
J Am Coll Surg. 2009 Dec;209(6):733-9
19959042
Acta Chir Iugosl. 2007;54(1):41-5
17633861
Dig Liver Dis. 2010 Apr;42(4):261-71
20138815
J Gastroenterol. 1999 Jun;34(3):420-3
10433025
World J Surg. 1984 Feb;8(1):41-50
6322458
Radiology. 2009 Feb;250(2):425-434
19188314
Rozhl Chir. 1999 Sep;78(9):457-60
11077875
Acta Gastroenterol Belg. 2005 Oct-Dec;68(4):428-31
16432995
Parasitol Int. 2010 Jun;59(2):257-61
20206293
Zentralbl Chir. 1995;120(6):455-60
7639033
Ann Hepatol. 2003 Jul-Sep;2(3):141-2
15115967
Acta Chir Belg. 2003 Feb;103(1):113-5
12658891
Cardiovasc Intervent Radiol. 1991 May-Jun;14(3):183-4
1878911
Ned Tijdschr Geneeskd. 1991 May 18;135(20):901-4
2046794
Gastroenterol Clin Biol. 1994;18(3):285-8
7926446
Am J Gastroenterol. 1983 Mar;78(3):182-4
6402924