Endoscopy Challenge #3 - May '10

A 7 year old boy with melena and anemia

History

7yo male with history of Wiskott- Aldrich syndrome, status post cord blood transplant, recently underwent ultrasound guided liver biopsy to evaluate elevated liver associated enzymes and hyperbilirubinemia. Liver biopsy revealed graft versus host disease and adenovirus infection. Approximately 10 days later, patient was readmitted for vomiting, diarrhea, and epigastric abdominal pain. Admission labs showed anemia and abdominal US detected echogenic material in gallbladder lumen. Pertinent physical exam findings included slightly distended abdomen, with epigastric and right upper quadrant tenderness. During hospital stay, patient developed melanotic stools with worsening anemia.

Upper GI endoscopy revealed the following finding:

Diagnosis

To evaluate melanotic stools and anemia, upper GI endoscopy revealed normal esophagus and stomach, but a pool of bile with evidence of fresh blood was seen in the duodenum. Exam with a side viewing scope (duodenoscope) revealed fresh blood draining from the major papilla see image.

Hemobilia secondary to liver biopsy was diagnosed, with ongoing bleeding likely due to thrombocytopenia. The patient eventually improved with time and platelet transfusions to maintain a level above 75,000.

Discussion

Hemobilia, or bleeding from the biliary tract, is seldom seen in the pediatric population and is not one of the more commonly considered etiologies of upper gi bleeding. Causes for hemobilia are pooled from various case reports of children who endured blunt abdominal trauma, complications status post liver transplant with biliary strictures requiring balloon dilatation, liver abscess, and liver biopsy. US guided liver biopsies are safe but there are rare complications such as pseudoaneurysm and arterial-biliary fistula1. The patient in this case report had a liver biopsy 2 weeks prior to presentation of abdominal pain, melanotic stools, and anemia.

Lillienne Yoon, MD
Fellow, University of Texas Southwestern

Brad Barth, MD
University of Texas Southwestern

References

  1. Wood B, Pearson N, Crisp M, Neese P, Pohl JF. Pseudoaneurysm formation after ultrasound-guided liver biopsy in an obese child. South Med J. 2009 Apr;102(4):432-4.