We report here a patient who suffered three complications after ultrasound-guided
percutaneous liver biopsy: hemobilia, acute biliary pancreatitis, and acute cholecystitis.
Endoscopic sphincterotomy and cholecystectomy were successfully carried out, allowing
a minimally invasive approach to manage these events.
A 21-year-old woman underwent an ultrasound-guided liver biopsy as part of a preoperative
kidney transplantation protocol. Her background included chronic renal failure due
to glomerulonephritis and hepatitis C. One hour after the procedure, she experienced
acute epigastric pain and melena, without hemodynamic compromise. Her hemoglobin level
decreased from 8.9 g/dl to 7.7 g/dl (normal range 13.5 - 15.0 g/dl). An ultrasound
examination demonstrated free peritoneal fluid and a large quantity of echogenic material
in the gallbladder. The following day, she developed nausea, vomiting, worsening pain,
and jaundice. Serum amylase was 600 U/l (normal: below 130 U/l), total bilirubin 11.5
mg/dl (normal: 0.2 - 1.0 mg/dl). She received three units of packed red blood cells.
Computed tomography and magnetic resonance cholangiopancreatography (MRCP) revealed
edematous pancreatitis, a dilated gallbladder, and clots inside the common bile duct
and gallbladder. Endoscopic retrograde cholangiopancreatography confirmed that there
were blood clots obstructing the major duodenal papilla (Figure [1]), and the cholangiogram demonstrated irregular filling defects throughout the bile
ducts and gallbladder (Figure [2]). Endoscopic sphincterotomy was carried out, and a large and hypertensive amount
of fresh blood clot was drained with a basket and a balloon catheter. A hepatic angiogram
did not show any evidence of further active bleeding. The patient’s condition and
jaundice initially improved, but 5 days later, recurrent abdominal tenderness over
the right upper quadrant, fever, and leukocytosis were noted. Ultrasound revealed
a distended gallbladder containing echogenic materials. A cholecystectomy was performed,
confirming blood clots and purulent fluid inside the gallbladder. The patient was
discharged home after a course of antibiotics, and has remained well in the last 18
months.
Video sequence may be viewed online: http://www.thieme-connect.com/DOI/DOI?10.1055/s-2005-870407
Figure 1 An impacted clot in the major duodenal papilla.
Figure 2 Clots inside the common bile duct (black arrow) and gallbladder (yellow arrow).
The average time observed between a liver biopsy and the onset of hemobilia is approximately
5 days [1]. Angiography can be useful both to confirm the diagnosis and to attempt treatment
by embolizing the bleeding vessel [2]. Ultrasound can detect clots in the dilated bile ducts and gallbladder. MRCP shows
a negative magnetic signal in the biliary duct and gallbladder, corresponding to blood
clots. When the blood clots completely obstruct the duodenal papilla, as observed
in the patient described here, jaundice and biliary pancreatitis may subside; this
observation has also been reported by other authors [3]
[4]. Acute cholecystitis has also been described after liver biopsy [5]. In the present case, the distended gallbladder full of large blood clots was not
able to empty itself even after sphincterotomy and wide biliary drainage, and cholecystectomy
was necessary to manage this complication.
Endoscopy_UCTN_Code_CPL_1AK_2AJ
