Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
J Emerg Med. 2020 May;58(5):e227-e229. doi: 10.1016/j.jemermed.2020.03.035. Epub 2020 Apr 27.
Hemobilia refers to bleeding in the biliary tract, commonly due to iatrogenic, traumatic, and neoplastic causes. It is a rare source of upper gastrointestinal hemorrhage, but it can be severe and fatal. However, gallstones account for 5%-15% of hemobilia cases.
A 60-year-old woman with diabetes mellitus and chronic kidney disease visited the emergency department with complaints of epigastric pain and vomiting of coffee ground-like content for 2 days. Physical examination revealed epigastric tenderness and hyperactive bowel sounds. Laboratory tests showed anemia with a hemoglobin count of 10.7 mg/dL and elevated liver function tests with total and direct bilirubin levels of 3.6 mg/dL and 2.5 mg/dL, respectively. Panendoscopy showed oozing of coffee ground-like material at the orifice of the ampulla of Vater and second portion of the duodenum, leading to suspicion of hemobilia. After admission, endoscopic retrograde cholangiopancreatography revealed common bile duct (CBD) dilatation with choledocholithiasis, biliary sludge, and filling defect at the middle section of the CBD. Endoscopic sphincterotomy with balloon lithotripsy was performed. After biliary decompression and broad-spectrum antibiotic administration, abdominal pain was relieved, and liver enzyme and total bilirubin levels improved. Symptoms of hemobilia depend on the bleeding rate and presence of bile duct obstructions due to clots. Minor and slow bleeding tend to form clots and cause biliary obstruction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although minor hemobilia may remain asymptomatic and tends to resolve spontaneously, the cause of hemobilia must be corrected to prevent recurrent bleeding or obstruction.
血胆汁是指胆道出血，常见病因包括医源性、创伤性和肿瘤性。它是上消化道出血的罕见病因，但可能很严重甚至致命。然而，胆结石占血胆汁病例的 5%-15%。
一名 60 岁女性，患有糖尿病和慢性肾脏病，因上腹痛和咖啡渣样呕吐 2 天就诊于急诊科。体格检查发现上腹部压痛和肠鸣音活跃。实验室检查显示贫血，血红蛋白计数为 10.7mg/dL，肝功能检查显示总胆红素和直接胆红素水平分别为 3.6mg/dL 和 2.5mg/dL 升高。全内镜检查显示 Vater 壶腹和十二指肠第二段口部有咖啡渣样物质渗出，提示血胆汁可能。入院后，内镜逆行胰胆管造影显示胆总管（CBD）扩张，合并胆总管结石、胆泥和 CBD 中段充盈缺损。行内镜下括约肌切开术联合球囊碎石术。胆道减压和广谱抗生素治疗后，腹痛缓解，肝酶和总胆红素水平改善。血胆汁的症状取决于出血速度和是否因血栓形成而导致胆管阻塞。少量和缓慢的出血容易形成血栓并导致胆管阻塞。
为什么急诊医生应该了解这一点？：尽管少量血胆汁可能无症状且倾向于自发缓解，但必须纠正血胆汁的病因，以防止再次出血或阻塞。
