A 45-year-old man comes to the emergency department for colicky, right upper quadrant pain; vomiting; and melena for 24 hours. He has no hematemesis. Medical history is significant for nonalcoholic steatohepatitis, which was diagnosed by percutaneous liver biopsy 5 days ago. The biopsy also showed mild fibrosis around portal tracts without bridging fibrosis or regenerative hepatocyte nodules. Temperature is 37.4 C (99.3 F), blood pressure is 95/60 mm Hg, pulse is 110/min, and respirations are 15/min. Scleral icterus is present. Cardiopulmonary examination is unremarkable. The abdomen is tender to palpation in the right upper quadrant. Laboratory results are as follows: Which of the following is the likely diagnosis?

Question

A 45-year-old man comes to the emergency department for colicky, right upper quadrant pain; vomiting; and melena for 24 hours.  He has no hematemesis.  Medical history is significant for nonalcoholic steatohepatitis, which was diagnosed by percutaneous liver biopsy 5 days ago.  The biopsy also showed mild fibrosis around portal tracts without bridging fibrosis or regenerative hepatocyte nodules.  Temperature is 37.4 C (99.3 F), blood pressure is 95/60 mm Hg, pulse is 110/min, and respirations are 15/min.  Scleral icterus is present.  Cardiopulmonary examination is unremarkable.  The abdomen is tender to palpation in the right upper quadrant.  Laboratory results are as follows:  Which of the following is the likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d8f6_eaa7_bc81_cdc0b2a6d1e4_MD0003_00 This patient who has melena, right upper quadrant (RUQ) pain, jaundice, anemia, and hyperbilirubinemia after a recent liver biopsy likely has bleeding into the biliary tract, known as hemobilia. Hemobilia is a rare cause of upper gastrointestinal bleeding (UGIB) that usually occurs as a complication of hepatic or biliopancreatic interventions (eg, liver biopsy, cholecystectomy, endoscopic cholangiopancreatography); other etiologies include hepatobiliary tumors and blunt trauma. Massive hemobilia results in hemodynamic instability and UGIB that occurs immediately after the procedure; intraductal hematoma formation more commonly results in delayed UGIB until after dissolution of the clot (usually ~5 days post-procedure). Patients typically present with RUQ pain, jaundice, and UGIB (eg, melena, hematemesis). Laboratory findings include direct hyperbilirubinemia from bile duct obstruction and anemia; leukocytosis (and reactive thrombocytosis) can occur due to inflammation. Abdominal imaging (eg, CT scan, ultrasound) can identify hematomas and intraabdominal free fluid, and endoscopic evaluation may reveal oozing of blood from the papilla. Hemobilia is usually self-limited and often managed conservatively (eg, intravenous fluids, blood transfusions); however, angiography with embolization or surgery may be required for persistent bleeding. (Choice A) Acute cholecystitis presents with RUQ pain and leukocytosis. However, cholecystitis causes neither hyperbilirubinemia nor jaundice (which typically occur with acute cholangitis), nor would it cause melena or anemia. It is also often associated with fever. (Choice B) Gallstone pancreatitis also presents with fever, vomiting, hyperbilirubinemia, and leukocytosis. However, the pain is typically epigastric and radiates to the back; melena and anemia are unexpected. (Choice C) Aortoenteric fistula causes massive gastrointestinal bleeding and usually results from a ruptured abdominal aortic aneurysm or after aortic surgery; it is not a typical complication of liver biopsy. In addition, hyperbilirubinemia and jaundice are unexpected. (Choice E) Liver abscesses can form after liver biopsy and present with RUQ pain, leukocytosis, and possibly hyperbilirubinemia when they compress the biliary tree; however, fevers are typical, and UGIB would not occur. (Choice F) A perforated duodenal ulcer can cause abdominal pain and melena, but the pain is usually generalized and severe (rather than focal RUQ pain) and associated with fever, abdominal distension, rebound, and guarding. Jaundice and hyperbilirubinemia are unexpected. Educational objective: Hemobilia (bleeding into the biliary tract) is a rare cause of upper gastrointestinal bleeding that usually occurs as a complication of hepatic or biliopancreatic procedures. It presents with right upper quadrant pain, jaundice, and upper gastrointestinal bleeding. References: Hemobilia and melena after liver biopsy: a case report and review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/27785254) Massive hemobilia: a diagnostic and therapeutic challenge. (http://www.ncbi.nlm.nih.gov/pubmed/24381048)

A 45-Year-Old Man Comes to the Emergency Department for Colicky