title: Massive hemobilia: a diagnostic and therapeutic challenge.
abstract: BACKGROUND
  Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. In this retrospective analysis, we have evaluated the challenges involved in the diagnosis and management of massive hemobilia.
  
  
  METHODS
  Between 2001 and 2011, a total of 20 consecutive patients (14 males) who were treated in our department for massive hemobilia were included in the study and their records were retrospectively analyzed.
  
  
  RESULTS
  Causes of hemobilia were blunt liver trauma (n = 9), hepatobiliary intervention (n = 4), post-laparoscopic cholecystectomy hepatic artery pseudoaneurysm (n = 3), hepatobiliary tumors (n = 3), and vascular malformation (n = 1). Melena, abdominal pain, hematemesis, and jaundice were the leading symptoms. All patients had undergone upper GI endoscopy, abdominal ultrasound, and computerized tomography of the abdomen. An angiogram and therapeutic embolization were done in 12 patients and was successful in nine but failed in three, requiring surgery. Surgical procedures performed were right hepatectomy (n = 4), extended right hepatectomy (n = 1), segmentectomy (n = 1), extended cholecystectomy (n = 1), repair of the pseudoaneurysm (n = 3), and right hepatic artery ligation (n = 1).
  
  
  CONCLUSIONS
  The successful diagnosis of hemobilia depends on a high index of suspicion for patients with upper GI bleeding and biliary symptoms. Although transarterial embolization is the therapeutic option of choice for massive hemobilia, surgery has a definitive role in patients with hemodynamic instability, after failed embolization, and in patients requiring laparotomy for other reasons.
authors.affiliation: Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai, 600001, India, dr.satishdevakumar@gmail.com.
authors.forename: Satish Devakumar
authors.initials: SD
authors.lastname: Murugesan
authors.forename: Jeswanth
authors.initials: J
authors.lastname: Sathyanesan
authors.forename: Anand
authors.initials: A
authors.lastname: Lakshmanan
authors.forename: Sukumar
authors.initials: S
authors.lastname: Ramaswami
authors.forename: Senthilkumar
authors.initials: S
authors.lastname: Perumal
authors.forename: Srinivasan Ulagendra
authors.initials: SU
authors.lastname: Perumal
authors.forename: Ravi
authors.initials: R
authors.lastname: Ramasamy
authors.forename: Ravichandran
authors.initials: R
authors.lastname: Palaniappan
mesh_terms: D000328:Adult; D000465:Algorithms; D017541:Aneurysm, False / Q000150:complications / Q000601:surgery*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects; D004621:Embolization, Therapeutic; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology* / Q000601:surgery; D006431:Hemobilia / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D006498:Hepatectomy; D006499:Hepatic Artery / Q000601:surgery*; D006801:Humans; D008099:Liver / Q000293:injuries / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D054079:Vascular Malformations / Q000150:complications; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000601:surgery; D055815:Young Adult