OVERVIEW
Infectious biliary hemorrhage refers to bleeding from the biliary tract caused by infection. Biliary bleeding due to simple bacterial infections is rare, and is most often caused by secondary infections of the biliary system due to factors such as biliary roundworms, bile duct stones, or strictures.
Etiology
Biliary tract infection due to various causes is the main cause of biliary bleeding seen in China, and its predisposing factors include biliary ascariasis, bile duct stones and biliary liver abscess. There are 3 pathogenesis: ① In acute purulent inflammation of the hepatic bile ducts, ulcers are formed on the mucosal surface, and some deep ulcers can penetrate the wall of the bile ducts and involve the wall of the accompanying blood vessels, which leads to the rupture of the vessel wall, and the blood flows into the bile ducts. ② Infection causes acute diffuse cholangitis, small cholangitis and pericholangitis in the liver, multiple small abscesses can be formed in the confluent area, and multiple hepatic cholangio-vascular fistulas occur due to necrotic liquefaction of hepatic tissues in some areas, and this lesion is often combined with gram-negative bacillus septicemia. (iii) In the late stage of multiple liver abscesses, the liver tissue between abscesses is destroyed, involving the adjacent hepatic bile ducts and blood vessels, forming infected aneurysms or portal vein dilatation, and then the dilated blood vessel wall protrudes into the damaged hepatic bile ducts, causing bleeding due to erosion and rupture of the vessel wall.
Symptoms
Mostly occurs on the basis of severe biliary tract infection or biliary ascariasis, the patient suddenly has upper abdominal colic, followed by massive bleeding from the upper gastrointestinal tract, although the bleeding can be temporarily stopped after treatment, but due to the special effect of bile, the bleeding recurs again after a few days to 2 weeks, due to the infection and bleeding, the patient’s condition deteriorates rapidly and seriously, and many patients can be complicated by multiple biliary liver abscesses.
Examination
1.Ultrasound examination
Ultrasound can detect dilatation of intrahepatic and extrahepatic bile ducts, stones of gallbladder and hepatic bile ducts, and space-occupying lesions of liver and pancreas.
2. CT and hepatic nuclear scanning
It can show space-occupying lesions.
3. Gastrointestinal barium meal X-ray examination
It can exclude bleeding caused by rupture of varices and ulcers in the lower esophagus.
4. Selective hepatic arteriography
Selective hepatic arteriography can detect intrahepatic space-occupying lesions, aneurysmal lesions of the hepatic artery, hepatic artery cholangiofistula, hepatic artery portal vein fistula, and abnormal lesions of the hepatic artery. Positive results of selective hepatic arteriography can provide a basis for treatment of biliary bleeding.
5. Fiberoptic endoscopy
The diagnosis of biliary hemorrhage is confirmed when blood is found to flow out of the jugular opening under endoscopy. At the same time, the bleeding lesions in the esophagus, stomach and duodenum should be understood and excluded.
Diagnosis
Based on the history of cholelithiasis, biliary ascariasis, hepatobiliary or pancreatic tumors, combined with the manifestations of recurrent upper gastrointestinal bleeding, the diagnosis is generally not difficult. The diagnosis can be further clarified based on the results of ultrasound, selective hepatic arteriography and fiberoptic endoscopy.
Treatment
Patients with infected biliary bleeding require immediate surgical treatment after a relatively short period of preparation to treat biliary infection and control bleeding. Currently commonly used methods to control bleeding are.
1. Ligation of the hepatic artery of the bleeding liver lobe or the innominate hepatic artery when the localization is not clear enough.
2. Lobectomy or partial hepatectomy. By percutaneous selective hepatic arteriography to understand the site of bleeding, at the same time can be inserted into the artery for the hepatic artery branch embolization, but this method requires complex equipment and skillful technology, at the same time can not deal with biliary pathology, so the use of some limitations. For extrahepatic biliary bleeding, surgery can identify the source of bleeding, if the bleeding comes from the gallbladder, cholecystectomy should be performed; if the bleeding comes from the hepatic artery, the branch of the hepatic artery should be resected or ligated, and simply suturing the mucosal surface of the bile ducts to the ulcer, which is generally not able to achieve the purpose of stopping bleeding, and can be re-ruptured and bleed after surgery. Surgery should be accompanied by treatment of the biliary tract lesion and establishment of adequate biliary drainage to control infection.