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Difficulty: HardSurgical and Procedural Interventions

A 56-year-old man is evaluated in the emergency department for right upper quadrant abdominal pain, jaundice, and black, tarry stools that started 24 hours ago. Five days ago, he underwent an ultrasound-guided percutaneous liver biopsy to evaluate undiagnosed cirrhosis. His temperature is 37.1°C (98.8°F), blood pressure is 102/64 mm Hg, pulse is 112/min, and respirations are 16/min. Physical examination shows scleral icterus and right upper quadrant tenderness without guarding or rebound. Laboratory studies reveal a hemoglobin level of 8.2 g/dL (baseline 13.5 g/dL) and a total bilirubin of 4.8 mg/dL. Following the administration of intravenous fluids and packed red blood cells, the patient undergoes an esophagogastroduodenoscopy. The esophageal and gastric mucosa are normal, and no varices are identified. However, fresh blood is observed actively extruding from the ampulla of Vater. Which of the following is the most appropriate next step in management?

  1. Angiography with selective transarterial embolizationAnswer
  2. B
    Endoscopic retrograde cholangiopancreatography with biliary stenting
  3. C
    Emergent exploratory laparotomy with hepatic artery ligation
  4. D
    Contrast-enhanced computed tomography of the abdomen and pelvis
  5. E
    Intravenous administration of octreotide and prophylactic antibiotics

Answer

Angiography with selective transarterial embolization
This patient presents with classic signs of hemobilia (Quincke's triad: right upper quadrant pain, jaundice, and upper gastrointestinal bleeding) five days after a percutaneous liver biopsy. The esophagogastroduodenoscopy confirms the diagnosis by visualizing fresh blood exiting the ampulla of Vater. Hemobilia in this context is most commonly due to an iatrogenic arteriobiliary fistula formed during the biopsy. Because the patient has significant bleeding (drop in hemoglobin, tachycardia), definitive intervention is required. Angiography with selective transarterial embolization is the gold standard and first-line therapy. It allows for both precise localization of the bleeding vessel and immediate therapeutic occlusion, avoiding the high morbidity of open surgery.

Step-by-Step Solution

1
Identify the clinical triad and endoscopic findings.
The patient presents with Quincke's triad (right upper quadrant pain, jaundice, and gastrointestinal bleeding) and endoscopic evidence of blood from the ampulla of Vater following a recent liver biopsy.
These findings definitively establish the diagnosis of hemobilia, typically caused by an iatrogenic arteriobiliary fistula.
2
Determine the optimal procedural intervention.
The patient requires immediate control of the arterial bleeding source.
Transcatheter arterial embolization is the preferred first-line treatment, offering high success rates with lower morbidity compared to open surgery.

Key Concept

Hemobilia often presents with Quincke's triad (right upper quadrant pain, jaundice, gastrointestinal bleeding) after hepatic instrumentation; the first-line definitive procedural management is angiography with selective transarterial embolization.
Estimated Time:1m 30s
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Topics

Surgical and Procedural Interventions

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