Precipitating factors:
(1) trauma (onset of bleeding may be delayed)
(2) cancer
(3) parasitic infection (Ascaris, Clonorchis)
(4) surgery, liver biopsy, cholangiogram
(5) pyogenic hepatic abscess
(6) vascular aneurysm
(7) gallstones
(8) severe coagulopathy
Diagnostic findings:
(1) evidence of gastrointestinal hemorrhage, including hematemesis and melena
(2) obstructive jaundice
(3) right upper quadrant pain, typically intermittent and suggesting biliary colic
Diagnostic tests:
(1) colonoscopy can exclude sources of lower GI tract hemorrhage
(2) esophagogastroduodenoscopy can exclude other sources of upper GI hemorrhage but may not always demonstrate bleeding from the ampulla, especially if the bleeding is mild and intermittent
(3) angiography is the most useful test, and allows for embolization of a bleeding vessel
(4) retrograde cholangiopancreatography may be helpful, but may be difficult if bleeding is moderate to severe
(5) CT scans and ultrasonography can help identify the cause (tumor, abscess). These can demonstrate dilatation of the biliary tree and identify blood clots but may not be able to localize the site of the bleeding.
Management:
(1) Angiography with embolization is adequate in many cases.
(2) Surgery may be required to ligate a vessel unresponsive to embolization, resect a tumor or if parasites are present.
