1. From Hemobilia to Hematochezia A 49-year-old woman transferred from an outside hospital because of severe hematochezia with a drop in hemoglobin from 14 to 8.3 g/dl.

2. She initially presented because of a sudden onset of intense and constant sharp pain in the epigastric area that started soon after food intake.

3. Two months prior to her hospitalization she underwent a laparoscopic cholecystectomy for recurrent abdominal pain.

4. Her surgery and initial recovery was uneventful although she occasionally experienced brief episodes of epigastric pain that were less intense and never lasted longer than 30 min.

5. prior medical history Her prior medical history was otherwise only remarkable for a quiescent ulcerative colitis.

6. physical examination The main findings on physical examination were icteric sclerae and mild skin icterus as well as dark blood in the rectal ampulla.

7. laboratory tests demonstrated a moderate elevation of her bilirubin with 4.7 mg/dl (direct bilirubin: 4.5 mg/dl) liver enzymes with alkaline phosphatase of 127 U/l, AST 197 U/l ALT 469 U/l.

8. ultrasound examination To further delineate the underlying problem an ultrasound examination was performed which demonstrated a fluid collection in the gallbladder fossa and a dilation of the intra- and extrahepatic biliary tree.

11. endoscopy An initial endoscopy with antegrade scope did not reveal a bleeding site in the proximal GI tract.

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13. side-viewing endoscope a prominent papilla was seen with the side- viewing endoscope. Upon intubation of the papilla, a significant amount of blood drained from the bile duct.

15. Contrast injection into the common bile duct demonstrated blood clots.

17. angiogram An angiogram showed a large aneurysm of the right hepatic artery with penetration and bleeding into the biliary tree.

19. Diagnosis The combination of abdominal pain, bleeding and icterus after cholecystectomy pointed at problems in the biliary tree.

20. Based on these findings, the patient underwent embolization of the feeding artery, which achieved hemostasis.

22. Discussion: Hemobilia is defined as blood in the biliary tree which can manifest as melena, hematochezia, and hematemesis or as a gradual blood loss associated with biliary colic and/or jaundice.

23. Only about 5 % of the patients with hemobilia present with all three signs and symptoms.

24. Etiology Etiology may be trauma, most often iatrogenic (50% in Western countries), infection (more common in 3rd World), malignancy, chronic inflammatory disorders, or gallstones.

25. The combination of acute biliary symptoms, jaundice and gastrointestinal bleeding should raise the suspicion for hemobilia, especially if the patient had recently undergone a liver biopsy (typically less than 5 days prior to presentation), a cholecystectomy or any surgical or endoscopic manipulations of the biliary system (up to 3-5 weeks prior to presentation).

26. The diagnosis of hemobilia can be made endoscopically when bleeding from the ampulla is seen.

27. Ultrasound and /or CAT scan may show intrahepatic fluid collections and / or ductal dilation.

28. Scintigraphy with labeled erythrocytes may suggest hemobilia and trigger the next step,

29. angiography that typically is diagnostic.

30. treatment In the past, treatment for hemobilia has mostly been surgical, frequently requiring a partial hepatectomy if the liver is source of bleeding.

31. Alternatively, hepatic ligation has been performed successfully. Based on the results of hepatic artery ligation, angiographic embolization has been tried with success rates exceeding 80 %, making it the initial treatment of choice in most patients.