Hemobilia is an uncommon but serious complication caused by a communication between the hepatic arterial circulation and the bile ducts(1). We report a 5-year-old child with hemobilia treated with arteria gel foam embolization, a management strategy widely reported in adults.

This boy presented with recurrent hematemesis for 3 months and epigastric pain for initial 1 month. This was preceded by a blunt abdominal trauma following a road traffic accident. There was no history of jaundice. Child was managed non-operatively elsewhere with 2 units of blood transfusion. On examination, he had pallor (hemoglobin 8 g/dL) and hepatomegaly.

Fig. 1. Selective celiac angiographic picture showing extravasation of contrast from branch of right hepatic artery.	Fig. 2. Post embolization angiographic picture.

CECT abdomen done 1 month after trauma revealed a hematoma in the segment VIII of the right lobe of the liver. Upper GI endoscopy was normal and ERCP done at the time of admission was also normal. On sixth day of hospitalization he developed an episode of hematemesis associated with abdominal pain. Emergency upper GI endoscopy revealed blood clots coming out of duodenal papilla. Patient underwent emergency celiac axis angiography via femoral route. The catheter was then super selectively advanced into the hepatic artery. DSA showed an aneurysm and leak from the peripheral branch of right hepatic artery (Fig.1). Selective embolization of this branch was performed using sterile 3-4 mm fragments of gel foam, which resulted in cessation of leak (Fig. 2). He was discharged after 3 days of uneventful recovery and did not have any recurrence of hematemesis after 4 weeks of follow up.

Hemobilia, a phenomenon of bleeding into the biliary tree, presenting as either melena (90%) or hematemesis (72%)(1), is an unusual cause of obscure upper gastrointestinal bleeding. The complete triad of bleeding, pain and jaundice is reported only in 22% of cases. In Sandblom’s review(2), the source of hemobilia was the liver in 52.7%, gallbladder in 23.1%, biliary ducts in 22.5% and pancreas in 1.7% of patients. The causes were accidental trauma (38.6%), operative trauma (16.6%), gallstones (14.9%), vascular disorders (10.7%) and tumors (6.2%)(2). A later review showed a paradigm shift in the causative factors with accidental and iatrogenic injury accounting for more than 60% of the cases(3).

Reports of management of traumatic hemobilia with embolization therapy in children are sparse. This report of a young boy of traumatic hemobilia has shown that treatment of hemobilia with embolization is effective and safe even in pediatric patients.

L.B. Gupta,
A.S. Puri,
Department of Gastroenterology,
G.B. Pant Hospital,
New Delhi 110 002, India.
E-mail: [email protected]   

1. Green MH, Duell RM, Johnson CD, Jamieson NV. Hemobilia. Brit J Surg 2001; 88: 773-786.

2. Sandblom P. Hemobilia. History, pathology, diagnosis, treatment. Springfielda, IL: 1972.

3. Yoshida J, Donehue PE, Nyhus LM. Hemobilia: Review of recent experience with a world wide problem. Am J Gastroenterol 1987; 82: 443-452.