CASE REPORT Hemobilia and Pancreatitis as Complications of a Percutaneous Transhepatic Cholangiogram Helen C. Redman, MD, and Ramon R. Joseph, MD Percutaneous transhepatic cholangiography prior to the onset of his illness. Initial laboratory studies in- (PTC) has become widely accepted as a valu- cluded a serum glutamic oxaloacetic transaminase level able procedure in differentiating cholestatic (SGOT) of 1200 units and a serum bilirubin value of 10 mg/100ml. He was treated on an ambulatory basis with jaundice from extrahepatic obstructive.jaundice satisfactory progress for six weeks when he noted the onset and also in demonstrating the site and nature of of intense pruritis, increasing .jaundice, and light-colored the obstruction. Patients are usually operated stools. Laboratory studies changed to show a more obstruc- upon shortly following the procedure if an ob- tive picture, with the bilirubin level rising to 45 mg/100 ml structing lesion is found, decreasing the risk of (50% direct), SGOT 110 units, and alkaline phosphatase 312 units, rising to 550 units. The stools were never acholic. bile peritonitis and intraperitoneal bleeding, the Prothrombin time was normal. A percutaneous liver biopsy two most common and most serious com- was interpreted as intrahepatic and canalicular cholestasis plications of PTC (1-3). A Gram-negative sep- (Figure 1) and nonspecific portal triaditis (Figure 2). How- ticemia is another serious complication which ever, with the persistence of the obstructive-type biochemi- may result from direct leakage of infected bile cal profile, it was decided to perform a PTC to exclude sig- nificant extrahepatic obstruction. Three attempts to enter a into the hepatic venous circulation (3, 4). Other bile duct using a Teflon-sheathed 18-gauge needle were uncommon complications including pneu- made under television fluoroscopic control using both aspi- mothorax and laceration of the gallbladder have ration and ir~jection of contrast material. No duct was en- also been reported. We performed a PTC on a tered. The patient tolerated the procedure well and there was no clinical evidence of hemorrhage or bile leakage. The 23-year-old clinical-laboratory technician who following day celiac angiography was performed to exclude developed hemobilia, common bile duct ob- any unsuspected hepatic or biliary abnormality (Figure 3- struction, and clinical pancreatitis following the 6). The major hepatic arteries were normal with no dis- procedure. He also underwent celiac angiog- placement or occlusion. In the capillary phase, however, raphy after the PTC. We report this case be- there was a triangular area of hepatic parenchyma that de- veloped a markedly increased stain in the target area of the cause of this unusual complication and because PTC. Small tortuous draining vessels were seen in this area. of the picture seen at celiac angiography. Seven days after the PTC the patient developed severe episodic right upper quadrant pain suggesting acute com- CASE REPORT mon duct obstruction. Recurrent episodes of this pain per- sisted for 25 days. Amylase which had been normal The patient was a 23-year-old male who was hospital- throughout his illness was found to be 360 Somogyi units on ized for hepatitis B antigen-negative hepatitis. The patient the 7th day, and rose to 975 units after a severe attack of was employed as a pathology laboratory technician and right upper quadrant pain on the 24th day. On the 28th day gave a history of having accidentally cut himself with a scal- after PTC, the patient developed melena, but his hematocrit pel used at the autopsy of a.jaundiced patient three months reading did not significantly alter. 1311 Rose Bengal liver scan suggested extrahepatic obstruction. Technesium 99M From the Departments of Radiology and Internal Medi- liver scan suggested diffuse hepatocellular dysfunction. cine, Wayne County General Hospital, Eloise, Michigan, and University of Michigan Medical School, Ann Arbor, Celiotomy and common duct exploration 32 days after Michigan. the PTC revealed blood clots obstructing the common bile Address for reprint requests: Dr. Helen Redman, Mount duct. These were removed by irrigation. No vascular repair Zion Hospital and Medical Center, Box 7921, San Fran- was necessary. T-tube operative cholangiogram was done, cisco, California 94120. and the patient made an uneventful recovery. Digestive Oiseases, Vol. 20, No. 7 (July 1975) 691 REDMAN & JOSEPH Fig 1. Photomicrograph of percutaneous liver biopsy. Hematoxylin-eosin preparation. Ar- row indicates intrahepatic bile plug. Fig. 2. Photomicrograph of percutaneous liver biopsy. Hematoxylin-eosin stain. Portal area showing lymphocytic infiltration interpreted as a nonspecific portal triaditis. 692 Digestive Diseases, Vol. 20, No. 7 (July 1975) COMPLICATIONS OF PTC Fig 3. The right hepatic artery has a replaced origin from the superior mesenteric artery. Digestive Diseases, Vol. 20, No. 7 (July 1975) 693 REDMAN & JOSEPH Fig 4. Right hepatic angiogram, arterial phase: The small branches of the deep and super- ficial cystic arteries (black arrow) are prominent. An early parenchymal liver stain is seen (white arrow). Vascular pattern in the remainder of the right lobe is normal. 694 Digestive Diseases, Vol. 20, No. 7 (July 1975) COMPLICATIONS OF PTC Fig 5. Late arterial phase: A dense parenchymal stain (arrow) has developed in the target area of PTC. The gallbladder wall is well seen. Digestive Diseases, Vol. 20, No. 7 (July 1975) 695 REDMAN & JOSEPH Fig. 6. Late parenchymal phase: Wormian draining vessels (arrow) are seen adjacent to the area of increased parenchymal stain. These channels are similar to those seen in the Budd- Chiari syndrome. Parenchymal accumulation of contrast medium throughout the remainder of the right lobe was slightly mottled. 696 Digestive Diseases, Vol. 20, No. 7 (July 1975) COMPLICATIONS OF PTC DISCUSSION were different from normal hepatic veins and it Hemobilia is a rather uncommon clinical was felt that they might be lymphatics. Their problem from any cause. Blunt abdominal resemblance to the abnormal vascular channels trauma is the most frequent cause but hemobilia seen in the Budd-Chiari syndrome is remark- may be secondary to surgery, especially follow- able. Possibly an hepatic venous branch was oc- ing liver biopsy and other needling proce- cluded during the PTC and the same vascular dures (5). Other less common causes include channels were draining the liver segment. ruptured hepatic aneurysm, gallbladder disease, Clain, however, states that the vessels seen in hepatic neoplasms, and, in the Far East, asca- the Budd-Chiari syndrome are not hepatic lym- riasis. If the bleeding is slight, anemia may be phatic channels (6). the only symptom. When bleeding is more sub- stantial, jaundice, paroxysmal pain, and hemor- rhage into the gastrointestinal tract occur. In massive bleeding, hepatic angiography can be useful in the diagnosis and location of the bleed- CONCLUSION ing artery. Clinical awareness of hemobilia is PTC is a simple and useful tool for differ- important if the proper diagnosis is to be entiating extrahepatic obstructive iaundice from reached. cholestatic.jaundice. It demonstrates the level of Complications following PTC are not com- the obstruction and may determine the nature mon, with a reported frequency of less than of the lesion, aiding in the surgical approach. 5~ (1, 4). Bile leakage is almost universal at However, it does carry significant risks. laparotomy following PTC in an obstructed bil- iary system though the volume is frequently small and significant morbidity slight. Some bleeding is also common but is seldom of signifi- cance. Gram-negative septicemia may occur if SUMMARY the obstructed biliary system is infected. Percutaneous transhepatic cholangiography Hemobilia is also known to occur during (PTC) was performed on a 23-year-old male PTC (3, 5). Clots in a distended common duct because of an atypical progression of hepatitis B can simulate gallstones or obscure a distal ob- antigen-negative hepatitis. No bile duct was en- structing lesion. The complication occurring in tered and the procedure was uneventful. How- this patient is unusual in that no bile duct was ever, celiac angiography the day following PTC demonstrated during the PTC, although small revealed abnormal liver vessels in the target ducts undoubtedly were entered and in that the area and the patient developed hemobilia and complication developed days after the proce- clinical pancreatitis, causing common duct ob- dure. While hemobilia frequently has a delayed struction. Symptomatology persisted until ce- onset after trauma, complications of PTC are liotomy 32 days after PTC. Clots were found generally expected to occur during the proce- obstructing the common bile duct. dure or within the next 24-48 hours. Com- This case is presented both because of the un- plications are also unusual in nonobstructed usual complications of PTC and the unusual patients. The complication was serious, even- angiographic abnormalities. It is suggested that tually necessitating surgical intervention. The PTC be reserved for the evaluation of patients findings at celiac angiography were considered when there is a specific indication for the proce- to be secondary to the trauma of the PTC. The dure either to differentiate cholestatic.jaundice area of staining was in the target area of all from extrahepatic .jaundice or to localize a site three PTC punctures. The draining vessels of obstruction before surgical intervention. Digestive