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IMAGES IN LIVER TRANSPLANTATION
Hemobilia and Pancreatitis After LiverTransplant BiopsyFeng Li,1 Kristin L. Mekeel,2 Mackam Eleid,1 M.E. Harrison,1 K. Sudhakar Reddy,2 Adyr A. Moss,2
and David C. Mulligan2
1Department of Gastroenterology and 2Transplant Surgery, Mayo Clinic, Phoenix, AZ
Received June 17, 2008; accepted June 21, 2008.
A 51-year-old male presented after liver transplant bi-opsy with severe abdominal pain. This occurred 2 yearsafter a combined liver-kidney transplant for end-stageliver disease from alcoholic cirrhosis and end-stage re-nal disease from chronic glomerulonephritis. His post-transplantation course was unremarkable. His othermedical history included hypertension. His was not onany anticoagulation medication, and his maintenanceimmunosuppression included tacrolimus and myco-phenolate mofetil. His liver and kidney function prior tobiopsy was normal (Table 1). At our institution, patientsroutinely undergo surveillance liver biopsy on a yearlybasis, and this was the only indication for biopsy.
The biopsy was performed in the right lobe by inter-ventional radiology under ultrasonographic guidancewith an 18-gauge BioPrince biopsy gun. A Doppler ul-trasound prior to biopsy was unremarkable. One hourafter the biopsy, the patient developed severe abdomi-nal pain. A noncontrast computed tomography (CT)scan of the abdomen looking for subcapsular hema-toma revealed an intraluminal density in the secondand third portions of the duodenum. Immediately afterthe CT scan, the patient passed a large bloody stool.Upon further review of the CT scan, the intraluminaldensities in the duodenum were thought to be bloodclots.
The patient remained hemodynamically stable. Hisrepeat laboratory values are listed in Table 1. His he-moglobin had dropped from 17.4 to 15.6 g/L, his totalbilirubin had increased to 5.2 mg/dL, and his lipasewas 1800 IU/L. At that time, he was made nil per os andwas treated with intravenous hydration and antibiotics.Magnetic resonance cholangiopancreatography (MRCP)was then obtained (Fig. 1). The MRCP demonstratedsignificant hemobilia, including obstructing blood clotswithin the common bile duct that were likely also oc-cluding the pancreatic duct. The patient responded wellto conservative therapy. The day after admission, hepassed a nonbloody stool, and his abdominal pain im-proved. His laboratory values all showed significant im-provement (Table 1). A repeat MRCP demonstrated res-olution of the hemobilia. His diet was reinstituted, andhe was discharged 2 days after admission.
Hemobilia is a rare complication of liver biopsy andcan lead to pancreatitis. In this case, the bleeding wastransient, and conservative management was success-ful. However, had the hemobilia continued, the patientmay have needed a hepatic angiogram with emboliza-tion. Also, if the common bile duct and/or pancreaticduct had remained obstructed from the blood clots, atherapeutic endoscopic retrograde cholangiopancreati-cogram may have been necessary for clot extraction.
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CT, computed tomography; HCT, hematocrit; HGB,hemoglobin; MRCP, magnetic resonance cholangiopancreatography; N/A, not applicable.Address reprint requests to Kristin Mekeel, Transplant Surgery, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85254. Telephone:480-342-1093; FAX: 480-342-2324; E-mail: [email protected]
DOI 10.1002/lt.21619Published online in Wiley InterScience (www.interscience.wiley.com).
LIVER TRANSPLANTATION 15:350-351, 2009
© 2009 American Association for the Study of Liver Diseases.
TABLE 1. Biochemical Values
Pre-Biopsy Post-Biopsy Discharge
HGB g/L 17.3 15.6 14.5HCT % 49.4 44.9 42AST IU/L 25 265 97ALT IU/L 21 194 110Total bilirubin
mg/dL0.7 5.2 2.7
Lipase IU/L N/A 1852 130Creatinine mg/dL 0.8 0.8 0.8
Abbreviations: ALT, alanine aminotransferase; AST,aspartate aminotransferase; HCT, hematocrit; HGB,hemoglobin; N/A, not applicable.
Figure 1. Series of coronal images (a,b,c) from a magneticresonance cholangiopancreaticogram. An irregular filling de-fect, consistent with hemobilia (blood clot a,b,c), is present inthe lower third of the common bile duct, with a clot possiblyobstructing the pancreatic duct (b).
HEMOBILIA AND PANCREATITIS 351
LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
