Hemobilia and other complications caused by percutaneous ultrasound-guided liver biopsy

Hemobilia accounts for approximately 3%of all major percutaneous liver biopsy complications,and rarely results from arterioportal fistula.We report a patient who suffered from four complications over 11 d after ultrasound-guided percutaneous liver biopsy:hemobilia,acute pancreatitis,acute cholecystitis,and multiple stomach ulcers.Digital subtraction angiography was done after consultation with doctors,and showed obvious arteriovenous fistula of the right liver.The hepatic artery was selected and embolized by spring orbs.The active bleeding was stopped after embolization of the hepatic artery.The patient was discharged home on day 12 after embolization and remained well.

Evaluation of selective hepatic angiography and embolization in patients with massive hemobilia

BACKGROUND: Massive hemobilia is a rare but potential- ly life-threatening cause of upper gastrointestinal hemor- rhage. Transarterial embolization is considered the first line of intervention to stop the bleeding for most causes of he- mobilia. This study was conducted to evaluate selective he- patic angiography and embolization in the diagnosis and treatment of patients with massive hemobilia. METHODS: The clinical data of 16 patients with massive hemobilia were analyzed retrospectively. These patients un- derwent emergency celiac and selective right or left hepatic artery angiography and treated by embolization using Gel- foam particles and/or coils. RESULTS: Hepatic artery angiography revealed hepatic ar- tery pseudoaneurysms in 6 patients, cystic artery pseudoa- neurysms in 2, diffuse hemorrhage of hepatic artery bran- ches in 5, and right hepatic artery-bile duct fistulae in 3. The patients were diagnosed rapidly by angiography and treated successfully by embolization of the hepatic artery branch proximal to the bleeding point, and hemorrhage was stopped immediately. Two patients were embolized the second time for rebleeding. Neither recurrence of bleeding nor serious complication was found during the fol- low-up for 3 months to 2 years. The other 2 patients whose hemorrhage failed to be controlled died several days later. CONCLUSION: Being safe, reliable and minimally inva- sive , selective hepatic artery angiography and embolization are effective in the diagnosis and treatment of massive he- mobilia.

Endoscopic-catheter-directed infusion of diluted(-)-noradrenaline for atypical hemobilia caused by liver abscess:A case report

BACKGROUND Hemobilia occurs when there is a fistula between hepatic blood vessels and biliary radicles,and represents only a minority of upper gastrointestinal hemorrhages.Causes of hemobilia are varied,but liver abscess rarely causes hemobilia and only a few cases have been reported.Here,we present a case of atypical hemobilia caused by liver abscess that was successfully managed by endoscopic hepatobiliary intervention through endoscopic retrograde cholangiopancreatography(ERCP).CASE SUMMARY A 54-year-old man presented to our emergency department with a history of right upper quadrant abdominal colic and repeated fever for 6 d.Abdominal sonography and enhanced computed tomography revealed that there was an abscess in the right anterior lobe of the liver.During hospitalization,the patient developed upper gastrointestinal bleeding.Upper gastrointestinal endoscopy revealed a duodenal ulcer bleeding that was treated with three metal clamps.However,the hemodynamics was still unstable.Hence,upper gastrointestinal endoscopy was performed again and fresh blood was seen flowing from the ampulla of Vater.Selective angiography did not show any abnormality.An endoscopic nasobiliary drainage(ENBD)tube was inserted into the right anterior bile duct through ERCP,and subsequently cold saline containing(-)-noradrenaline was infused into the bile duct lumen through the ENBD tube with no episode of further bleeding.CONCLUSION Hemobilia should be considered in the development of liver abscess,and endoscopy is essential for diagnosis and management of some cases.

Hemobilia Due to an Iatrogenic Arteriobiliary Fistula Complicating Laparoscopic Cholecystectomy: A Case Report

Hemobilia is the result of a pathological communication between bile duct and intra or extrahepatic vessel. 40% to 60% of the haemobilia cases are Iatrogenic, and the other causes are either vascular malformations or hepatic blunt trauma. We describe the case history of a patient in which laparoscopic cholecystectomy was complicated 3 months later by massive hemobilia. The cause of haemorrhage was a fistula between the principal bil duct and the right hepatic artery. This complication was successfully managed by surgery and angiographic embolization with full recovery of the patient.

An Unusual Life-Threatening Hemobilia Caused by Hepatic Pseudoaneurysm Following Choledochostomy: A Case Report

The present report describes a case of hemobilia caused by hepatic pseudoaneurysm. A 63-year-old woman was admitted with abdominal pain and mild jaundice. She was diagnosed as choledocholithiasis and hypersplenism and underwent choledocolithotomy and splenectomy. 9th day post operation, massive fresh blood suddenly flew out from T tube and she underwent emergency abdominal exploration but there were no obvious bleeding sites in the abdominal cavity and no bleeding sites in the biliary tree by choledochoscope. 7th day after the second operation, fresh blood suddenly flew out from T tube again and angiography showed two small peudoaneurysms at the second branch of right hepatic artery which might result in hemobilia. The hemobilia was treated successfully with coil embolisation of peudoaneurysms and she recovers fully.

Hemobilia secondary to hepatic artery pseudoaneurysm: An unusual complication of bile leakage in a patient with a history of a resected Ⅲb Klatskin tumor

我们由于 resected 门 cholangiocarcinoma (类型 IIIb Klatskin 肿瘤) 与双 bilo 伤寒吻合的 16 年的历史报导一个 74 岁的女人的一个案例。与对导致了大肝内 biloma 的良性的吻合狭窄第二等的胆管炎介绍的病人。以便恢复吻合的明显并且克服胆管炎，几次尝试发生了，包括 endobiliary 小型机关枪的一种叮当响，帮助汽球的 biloplasty 和 transhepatic billiary 排水。吻合明显被完成，复杂，然而由坚持上面的胃肠的流血，作为胆道出血介绍了。左肝的动脉的一个导致 biloma 的假动脉瘤被诊断。这破裂了进胆道，并且介绍了胆道出血的实际原因。假动脉瘤的选择栓塞控制出血结果，并且成功地与吻合的 transhepatic 膨胀和 biloma 的经皮的排水被相结合。病人最终被治好并且似乎处于优秀状况， 5 瞬间术后疗法。

Hemobilia as the initial manifestation of cholangiocarcinoma in a hemophilia B patient

Hemobilia is a rare manifestation of hemophilia and is usually iatrogenic following liver biopsy. There are only few reports of spontaneous hemobilia in hemophilia patients. Cholangiocarcinoma is a well-established cause of hemobilia. We describe a case of a 70-year-old male, with known haemophilia B and a past history of papillotomy, who presented with classical symptoms of hemobilia. The initial diagnostic work-up failed to demonstrate a potential cause of bleeding other than the coagulopathy. Three months later, he was readmitted to our hospital with a second episode of hemobilia. During the second work-up, a cholangiocarcinoma was diagnosed both by imaging studies and by a significant elevation of cancer antigen 19-9. Although hemobilia could be attributed to hemophilia, especially in a patient with previous papillotomy, an underlying malignancy of the biliary tree should be suspected.

Percutaneous liver biopsy complicated by hemobilia-associated acute cholecystitis

肝活体检视通常被认为一只保险箱和高度有用的过程。它经常在众多的肝混乱为诊断和后续在一个门诊病人背景被执行。自从它在第 19 世纪，宽广经验，新成像技术和专辑的结束的介绍，针显著地减少了与肝活体检视联系的复杂并发症的率。肝的经皮的活体检视的已知的复杂并发症包括血腹膜，代替胶囊的血肿，低血压，气胸和败血。另外的 intra 腹的复杂并发症是不太普通的。胆道出血由于 arterio 胆汁的管管被描述了，它临床上仅仅很少被表示了为胆汁或胰腺炎。我们报导开发了在经皮的肝活体检视以后的 12 天在一个门诊病人背景执行了的严重尖锐胆汁的十五个 57 岁的男孩的一个案例。病原学清楚地被表明联系 hemobilia，并且临床的功课要求了 laparoscopic 胆囊炎的表演。起作用的柱子路线是平静的，病人回家被解除。经皮的肝活体检视是一个安全、通常执行的过程。然而，严重复杂并发症能偶尔发生。当处理这些稀罕事件时，医药、外科的选择应该被评估。

Gallbladder polyp as a manifestation of hemobilia caused by arterial-portal fistula after percutaneous liver biopsy: A case report

Outpatient percutaneous liver biopsy is a common practice in the differential diagnosis and treatment of chronic liver disease. The major complication and mortality rate were about 2-4% and 0.01-0.33% respectively. Arterio-portal fistula as a complication of percutaneoos liver biopsy was infrequently seen and normally asymptomatic. Hemobilia, which accounted for about 3% of overall major percataneous liver biopsy complications, resulted rarely from arterioportal fistula We report a hemobilia case of 68 years old woman who was admitted for abdominal pain after liver biopsy. The initial ultrasonography revealed a gallbladder polypoid tumor and common bile duct (CBD) dilatation. Blood clot was extracted as endoscopic retrograde cholangiopancreatography (ERCP) showed hemobilia. The patient was shortly readmitted because of recurrence of symptoms. A celiac angiography showed an intrahepatic artedo-portal fistula. After superselective embolization of the feeding artery, l^e patient was discharged uneventfully. Most cases of hemobilia caused by percutaneous liver biopsy resolved spontaneously. Selective angiography embolization or surgical intervention is reserved for patients who failed to respond to conservative treatment.

Hemobilia due to hepatic artery aneurysm as the presenting sign of fibro-muscular dysplasia

Fibro-muscular dysplasia(FMD)is a rare but well documented disease with multiple arterial aneurysms. The patients,usually women,present with various clinical manifestations according to the specific arteries that are affected.Typical findings are aneurysmatic dilatations of medium-sized arteries.The renal and the internal carotid arteries are most frequently affected, but other anatomical sites might be affected too.The typical angiographic picture is that of a"string of beads". Common histological features are additionally described. Here we present a case of a 47-year-old woman,who was hospitalized due to intractable abdominal pain.A routine work-up revealed a liver mass near the portal vein.Before a definite diagnosis was reached,the patient developed massive upper gastrointestinal bleeding.In order to control the hemorrhage,celiac angiography was performed revealing features of FMD in several arteries, including large aneurysms of the hepatic artery.Active bleeding from one of these aneurysms into the biliary tree indicated selective embolization of the hepatic artery.The immediate results were satisfactory,and the 5 years follow-up revealed absence of any clinical symptoms.

Hemobilia: Etiology, diagnosis, and treatment

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon but important cause of gastrointestinal hemorrhage.Reports of hemobilia date back to the 1600s,but due to its relative rarity and challenges in diagnosis,only in recent decades has hemobilia been more critically studied.The majority of cases of hemobilia are iatrogenic and caused by invasive procedures involving the liver,pancreas,bile ducts and/or the hepatopancreatobiliary vasculature,with trauma and malignancy rep-resenting the two other leading causes.A classic triad of right upper quadrant pain,jaundice,and overt upper gastrointestinal bleeding has been described(i.e.Quincke's triad),but this is present in only 25%e30%of patients with hemobilia.Therefore,prompt diagnosis depends critically on having a high index of suspicion,which may be based on a patient's clinical presentation and having recently undergone(peri-)biliary instrumentation or other predisposing factors.The treatment of hemobilia depends on its severity and suspected source and ranges from supportive care to advanced endoscopic,interventional radiologic,or surgical intervention.Here we provide a clinical overview and update regarding the eti-ology,diagnosis,and treatment of hemobilia geared for specialists and subspecialists alike.

经皮肝穿刺胆管引流术后胆管大出血的介入治疗

目的探讨介入疗法治疗经皮肝穿刺胆管引流术(PTCD)后胆管大出血的临床应用价值。方法对9例PTCD术后胆管大出血患者进行选择性血管造影和引流管造影,证实责任血管后进行介入治疗。结果对2例动脉胆管瘘患者行超选择性责任血管出血点近端和远端栓塞,6例假性动脉瘤患者行超选择性动脉瘤远端、假性动脉瘤及近端栓塞,对1例胆管门静脉主干瘘患者行胆管内覆膜支架植入术。术后所有患者出血均停止,经3～6个月随访后均无再出血。结论介入疗法治疗PTCD术后胆管大出血安全有效,创伤小。

经皮肝穿胆汁引流术后胆道出血的临床分析

目的回顾经皮肝穿胆道引流术后胆道出血发生与处理措施。方法无法或不能耐受手术的梗阻性黄疸患者139例,经常规经皮肝穿胆管造影后,一步法或二步法穿刺扩张胆道,放置外引流管或内外引流管及金属内支架留置,临床观察治疗前后总胆红素指标改变及手术相关并发症,处理胆道出血。结果全部患者经皮经肝穿刺胆道引流手术成功,治疗后总胆红素明显下降,由360μmol/L降至158.2μmol/L,使用止血药物43例,11例轻微胆道出血,调整引流管及应用止血药后停止,5例严重胆道出血,4例肝动脉损伤,其中3例肝动脉栓塞治疗成功,1例失败。结论经皮经肝穿刺胆汁引流可并发胆道出血,能及时有效控制,术者应不断提高穿刺水平,减少胆道出血并发症发生。

医源性胆道出血的血管造影表现和介入治疗

目的评价医源性胆道出血中血管造影诊断及介入栓塞治疗的价值。方法回顾性分析医源性胆道出血患者21例。经皮选择性肠系膜上动脉、腹腔动脉和肝总动脉造影,明确出血的部位后,进行选择性或超选择性插管及栓塞治疗。结果 21例患者血管造影均证实有出血病变。血管造影表现为假性动脉瘤者17例(81.0%),对比剂外溢者4例(19.0%)。栓塞材料采用PVA颗粒栓塞者2例,单纯弹簧圈8例,明胶海绵颗粒+弹簧圈11例。1次栓塞止血成功率为85.7%(18/21),3例患者栓塞后再次大出血而行第2次栓塞成功。术后随访5～28个月,患者均未再发胆道出血。所有患者介入栓塞术后均未出现异位栓塞、肝功能衰竭、栓塞所致感染等严重并发症。结论经皮选择性血管造影和介入栓塞术微创、安全、可靠且疗效确切,是诊断和治疗医源性胆道出血的首选方法。

妇科内分泌疾病诊治流程图

更年期综合征、闭经及月经过多是妇科常见病。在门诊工作中对该症候群做出快速诊断与治疗,是临床实践的要点。闭经分为原发性闭经及继发性闭经,原因诸多,下丘脑、垂体、卵巢等病变及阴道闭锁、子宫缺失、药物、内分泌疾病等均可以引起闭经。月经过多也是女性生殖系统疾病常见的临床症状,引起月经过多的原因多样,如何根据临床症状迅速寻找病因并对症治疗至关重要。本文根据近年来新颁布的临床诊疗指南,结合妇科内分泌疾病的临床诊疗经验,制定了有关更年期综合征、原发性闭经、继发性闭经及月经过多的诊治流程图,以方便广大妇产科临床工作者更快速、准确地对以上疾病进行诊断及治疗。

肝动脉假性动脉瘤相关胆道出血介入治疗效果

目的探讨肝动脉假性动脉瘤相关胆道出血(PARH)介入治疗效果。方法回顾性分析2012年3月至2016年12月采用血管栓塞术治疗的28例肝动脉假性动脉瘤所致胆道出血患者临床资料。术中血管造影明确假性动脉瘤形态、位置、大小,予以超选择栓塞治疗。术后对症处理,通畅胆道引流,定期随访。结果 28例患者肝动脉PARH诊断明确,胆道出血通过介入栓塞治疗均及时得到控制。术中共应用弹簧圈110枚,无相关并发症发生。术后随访1~36个月,1例肝门部胆管癌患者于介入术后4周死于感染及肝衰竭,2例胆总管癌患者分别于介入术后11.5、14.2个月死于肿瘤进展,2例胃癌患者分别于介入术后4、6.5个月死于肿瘤进展,1例胆总管结石腹腔镜术后患者于介入术后5个月死于并发症冠心病,其他患者恢复良好。结论介入治疗肝动脉PARH安全、可行,疗效确切。

肝胆管结石伴胆道出血51例原因分析及处理方法

目的探讨肝胆管结石患者胆道出血的原因及处理方法。方法回顾性分析我院收治的51例肝胆管结石伴胆道出血患者的出血原因,总结其治疗方法。结果51例患者中,16例为术前出血患者,其中胆总管结石、胆囊结石6例(其中5例行EST网篮取石),严重胆管炎症及胰腺炎6例,细菌性肝脓肿4例;35例为胆道术后出血患者,其中胆总管切开取石术后32例,胆肠吻合术后2例,肝切除术后1例。10例患者经保守治疗后9例痊愈,1例死亡;32例行肝动脉血管造影与介入栓塞治疗,29例止血成功,2例再次出血后行手术治愈,1例死亡;11例(包括2例介入治疗无效者)行手术治疗,均痊愈。结论胆道出血患者多合并肝内外胆管结石。应迅速分析胆道出血的原因及部位,结合出血量来选择治疗手段。在条件允许的情况下,肝动脉血管造影与栓塞是术后胆道出血诊治的首选方法,而合理地选择手术时机是提高疗效的关键。

治疗性内镜逆行胰胆管造影术后并发胆道出血的客观危险因素分析

目的探讨治疗性内镜逆行胰胆管造影术(ERCP)后并发胆道出血的客观危险因素。方法回顾性分析该院收治的285例患者术后行治疗性ERCP的临床资料。根据术后是否出现胆道出血,分为出血组和非出血组,并对发生胆道出血的客观危险因素进行分析。结果 285例患者中共23例患者出现ERCP术后胆道出血,发生率为8.07%。出血组患者胆管癌、壶腹部癌及胰头癌所占比例明显高于非出血组(P <0.05)。出血组患者合并胆道感染及十二指肠乳头憩室,发生率明显高于非出血组(P <0.05)。亚组分析显示,出血组与非出血组相比,结石直径≥2 cm、结石嵌顿和十二指肠乳头内憩室所占比例均明显升高(P <0.05)。结论胆道出血是治疗性ERCP术后常见并发症,恶性胆胰肿瘤、胆总管结石直径≥2 cm、结石嵌顿和十二指肠乳头内憩室均是术后胆道出血的危险因素,针对上述因素加强围手术期管理可降低术后胆道出血风险。

胆道出血的介入诊断与治疗(附3例报告)

目的 探讨介入在诊断与治疗胆道大出血中的应用价值。 方法 对 2例肝外伤手术后及 1例胆道结石手术后多次胆道大出血病人采用Seldinger技术行肠系膜上动脉及肝动脉插管DSA检查 ,显示胆道出血血管的部位、出血分布、假性动脉瘤及动静脉瘘形成情况 ,然后用微导管插管至出血血管分支 ,应用NBCA、PVA颗粒、明胶海绵及弹簧钢圈选择性栓塞。 结果 2例为弥漫性出血 ,1例为局限性出血 ,2例有假性动脉瘤形成 ,1例有肝动脉 -门静脉瘘形成。栓塞后造影显示出血血管成功栓塞 ,出血症状迅速停止。 结论 介入是胆道大出血诊断与治疗的有效措施。

手术后胆道出血的处理——附21例治疗体会

目的 :探讨手术后胆道出血的诊断与治疗方法的选择。方法 :分析 13年内处理的 2 1例胆道外科手术后胆道出血患者的资料 ,从患者的年龄、高血压病史、手术方式、术后出血时间、临床表现、诊断方法、肝动脉栓塞或手术治疗等方面总结手术后胆道出血的处理经验。结果 :2 1例患者中男 13例 ,女 8例 ;有高血压病史者12例 ;16例经肝动脉造影明确诊断并肝动脉栓塞治疗 ;5例直接经手术处理 ,其中 2例经两次手术。全部患者治疗后均未发生再出血。结论 :在条件允许情况下 ,肝动脉血管造影与栓塞是术后胆道出血诊断与治疗的首选可靠方法。