Hemobilia is defined as bleeding into the biliary tract and presents classically with Quincke's triad (right upper quadrant pain + jaundice + GI bleeding). The most common cause is iatrogenic trauma (65%) — developing after liver biopsy, ERCP, percutaneous biliary drainage, or cholecystectomy. Other causes include hepatic artery aneurysm, tumor invasion, gallstone erosion, and vascular malformations. CT angiography and angiography are gold standard for diagnosis, and selective arterial embolization is the preferred treatment approach. Massive hemobilia can be life-threatening and requires emergency intervention.
Age Range
20-80
Peak Age
50
Gender
Equal
Prevalence
Rare
Hemobilia develops from pathologic connection (fistula) between arterial or venous vascular structures and the biliary system. The most common cause of arterio-biliary fistula is iatrogenic trauma — liver biopsy needle or percutaneous drainage catheter can create pseudoaneurysm and fistula between hepatic artery branch and bile duct. When hepatic artery aneurysm ruptures, blood drains into the bile duct. Tumor invasion (HCC, cholangiocarcinoma) erodes vessel wall leading to hemobilia. Blood coagulates within the bile duct forming intraluminal blood clot — these clots can cause obstructive jaundice. In imaging, high-density material (acute blood) within bile duct or gallbladder, active contrast extravasation or pseudoaneurysm on CT angiography is seen. On angiography, contrast passage into bile duct (arterio-biliary fistula) is pathognomonic.
Contrast passage from hepatic artery branch to bile duct on CT angiography or conventional angiography — most specific finding of hemobilia. Allows simultaneous diagnosis and treatment (embolization).
High-density (>60 HU) intraluminal material within bile duct or gallbladder on non-contrast CT — representing acute blood. Normal bile fluid is 0-15 HU; intraluminal content with >60 HU density strongly suggests acute hemorrhage. Blood clots may be seen as irregular filling defects. High-density material may be seen in both intrahepatic and extrahepatic ducts. Hematoma in liver parenchyma along biopsy tract may accompany.
Report Sentence
High-density intraluminal material within bile duct/gallbladder on non-contrast CT is noted, consistent with hemobilia.
Round, intensely enhancing pseudoaneurysm from hepatic artery branch or active contrast extravasation into bile duct lumen on arterial phase. Pseudoaneurysm is usually located near the biopsy tract or drainage catheter trajectory. Active extravasation appears as amorphous contrast accumulation and expands in portal venous phase (sign of active bleeding). Hepatic artery anatomy and variations should be evaluated — critical for embolization planning.
Report Sentence
Pseudoaneurysm from hepatic artery branch / active contrast extravasation into bile duct on arterial phase indicating the source of hemobilia.
Hyperintense intraluminal material within bile duct or gallbladder on T1-weighted images — reflecting methemoglobin content of subacute blood. Acute blood may be isointense or mildly hyperintense on T1; in subacute period (3 days-3 weeks) T1 signal markedly increases with methemoglobin formation. On T2, acute blood is hypointense, subacute blood shows variable signal. Pre-contrast fat-suppressed T1 sequences are most sensitive for detecting intraluminal blood.
Report Sentence
Hyperintense intraluminal material within bile duct on T1-weighted series consistent with subacute intraluminal blood (hemobilia).
Echogenic intraluminal material within bile duct or gallbladder on US — NO acoustic shadow (distinguishing feature from stones). Blood clots show irregular, heterogeneous echogenicity and may move with position change (but less mobile than stones). Layered appearance (biliary sludge + blood mixture) may be seen in gallbladder. No vascularity in intraluminal material on Doppler.
Report Sentence
Echogenic intraluminal material without acoustic shadow within bile duct/gallbladder is noted, which may be consistent with blood clot (hemobilia).
Hypodense hematoma or active contrast extravasation along biopsy/drainage tract in liver parenchyma on portal venous phase. Hematoma is traced with irregular borders and lower density than surrounding parenchyma. Opening point to intrahepatic bile ducts may be visible — showing the source of hemobilia. Perihepatic free fluid (hemoperitoneum) may accompany.
Report Sentence
Hematoma along biopsy tract in liver parenchyma with opening point to bile duct noted, consistent with source of hemobilia.
Criteria
Hemobilia developing after interventional procedure (65%)
Distinct Features
Pseudoaneurysm along biopsy/drainage tract; usually successful treatment with embolization
Criteria
Hemobilia due to hepatobiliary tumor invasion
Distinct Features
Connection between tumor mass and vascular structure; treatment more complex (embolization + tumor treatment)
Criteria
Hemobilia due to hepatic artery aneurysm rupture or AVM
Distinct Features
Aneurysm or AVM detected; emergency embolization or surgery may be needed
Distinguishing Feature
Choledocholithiasis shows echogenic stone + posterior acoustic shadow; blood clot in hemobilia does NOT create acoustic shadow
Distinguishing Feature
Biliary sludge is low-density (10-25 HU) and homogeneous; intraluminal blood in hemobilia is high-density (>60 HU)
Distinguishing Feature
Acute cholangitis shows fever + duct wall enhancement; hemobilia shows high-density intraluminal blood + pseudoaneurysm
Distinguishing Feature
Cholangiocarcinoma forms mass/thickening at duct wall; hemobilia shows intraluminal blood + vascular source (aneurysm, fistula)
Urgency
emergentManagement
interventionalBiopsy
Not NeededFollow-up
specialist-referralHemobilia may require emergency intervention — hemodynamic instability and shock may develop in massive bleeding. Selective hepatic artery embolization is first-line treatment (80-100% success). If embolization fails, surgical ligation or hepatectomy is considered. Iatrogenic hemobilia may be self-limited but treatment is recommended in the presence of pseudoaneurysm due to rupture risk. CT angiography + conventional angiography is gold standard in diagnosis and treatment.
Hemobilia may require urgent interventional radiology or surgical consultation. While most iatrogenic cases (post-ERCP, post-biopsy) resolve with conservative treatment, angiographic embolization is life-saving in cases with pseudoaneurysm. Hemodynamic instability can develop in massive hemobilia.