Quick or Quincke's thinking?

October 13, 2015 By: Alexandre Ferreira & Jorge Brito

Figure 1a-c | The endoscopic appearance of the duodenal ampulla.

Figure 2 | The pseudoaneurysm of the inferior pancreaticoduodenal artery and chronic pancreatitis was successful treated during selective arteriography by embolisation with polyvinyl alcohol particles.

Alexandre Ferreira is a newly appointed GI consultant at Hospital Beatriz Ângelo, Loures, Portugal.

Jorge Brito is a consultant radiologist at Centro Hospitalar do Algarve, Portugal.

Quick or Quincke's thinking?

What next for a patient who's recently been feeling unwell & passing black stools?

A 40-year-old male patient went to his local A&E department with a short history of feeling unwell and passing black stools. He had a past history of chronic pancreatitis that was attributable to alcohol and a bleeding peptic ulcer some 15 years earlier. He was not taking any medication. On admission, the patient was pale with a heart rate of 75 BPM and his blood pressure was 125/80 mm Hg. The patient’s Hb level was 36 g/L, with a mean corpuscular volume of 8.93, iron 1.253 mmol/L and ferritin 0.27 pmol/L. On endoscopy, the oesophagus and stomach were unremarkable and the photographs show the appearance of the duodenal ampulla (figure 1a–c).

 

WHAT WOULD YOU DO NEXT?

a)     Endoscopic retrograde cholangiopancreatography (ERCP)

b)     Percutaenous transhepatic cholangiogram

c)     Abdominal computed tomography (CT)

d)     Angiogram

e)     Abdominal ultrasound

Discussion

If you look more carefully at the photograph you can see blood trailing away below the bile. This patient has haemobilia.

Classic haemobilia was first described in 1654 by Francis Glisson.1 However, the first documented case report is attributed to Antoine Portal in 1777!2 The classic clinical presentation of bleeding into the biliary tract is of ‘Quincke’s triad’: gastrointestinal haemorrhage, biliary colic and jaundice.  The typical biliary colic has been attributed to clots forming in the biliary tree, but it has also been suggested that substances in bile prevent the development of clots. An alternative possibility is that the pain is due to distension of the biliary tree by free-flowing blood.

Naturally, haemobilia is usually associated with percutaneous liver procedures such as percutaneous cholangiography, cholecystectomy or abdominal trauma. Less commonly haemobilia arises when a splanchnic vessel pseudoaneurysm has developed a communication with the intrahepatic or extrahepatic biliary system. The most common offending vessels include the cystic artery or the hepatic artery. Fistulas between the hepatic artery and the portal vein are less common. Finally, a pseudoaneurysm of the inferior gastroduodenal artery communicating with the pancreatic duct is decidedly rare!

The preferred investigation for haemobilia is angiography because it allows therapeutic intervention. The case patient underwent selective arteriography, which confirmed a pseudoaneurysm of the inferior pancreaticoduodenal artery and chronic pancreatitis. The aneurysm was successfully embolised with polyvinyl alcohol particles (figure 2). Embolisation is now the treatment of choice rather than surgical repair.

 

References

  1. Glisson F. Anatomia Hepatis. London, 1654.
  2. Portal A. des maladies dont on fixe ordinairement le siege dans le foie quoi qu’il n’y soit pas. Histoire de L’Academie Royale Sciences, Anee 1777, 1780, p601.
  3. Quincke H. Ein Fal von Aneurysmader Leberarterie. Klin Wochenschr 1871; 8: 349–351.

 

 

 

Answer

Correct answer: d.

 

 

About the authors

Alexandre Ferreira is a newly appointed GI consultant at Hospital Beatriz Ângelo, Loures, Portugal. Jorge Brito is a consultant radiologist at Centro Hospitalar do Algarve, Portugal.

 

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