Abstract
“Bleeding Ducts: Hemobilia, a Rare Presentation of Intraductal Papillary Neoplasm of the Bile Duct”
Leanne Elaine L. Lu, MD
St Lukes Medical Center Quezon City
Significance: Intraductal papillary neoplasm of the bile duct (IPNB) is rare premalignant bile duct neoplasm which account for 7-30% of bile duct tumors. Common clinical manifestations include abdominal pain, cholangitis and jaundice.
Clinical Presentation: A 70 year old woman presented with persistent melena with subsequent anemia (hemoglobin 6.2 g/L). Prior endoscopic examinations did not show any actively bleeding lesions. On admission, patient still presented with melena, mild epigastric pain, and pallor but no jaundice or fever.
Management: A second look EGD was done revealing hemobilia. Patient then underwent mesenteric angiogram s/p particle embolization of selected arteries and intraoperative ultrasound revealed multiple hepatic heterogenous foci. Whole abdominal CT scan revealed no hepatic mass lesions, common bile duct (CBD) and intrahepatic duct (IHD) dilatation and a 1 cm nodular enhancing focus in the proximal CBD. Spyglass cholangioscopy done revealed a lobulated polypoid lesion with villous surface at the main right IHD. Patient then underwent choledochoscopy with laser ablation of multiple bilateral intrahepatic duct tumors, excision of common hepatic duct mass, and t-tube choledochostomy. Frozen section revealed intraductal papillary mucinous neoplasm of the bile duct, predominantly low grade with focal high grade dysplasia.
Recommendation: In patients with obscure overt GI bleeding, a higher index of suspicion for other causes of bleeding such as hemobilia should be present. Hemobilia in IPNB may occur due to the infiltration into the adjacent liver parenchyma and vasculature. IPNB is a precursor lesion for malignancy with a relatively good prognosis hence the need for early surgical management.
Important Dates to Remember
| JRRE Activities 2023-2024 |
Proposed Dates |
|---|---|
| Resumption of face-to-face Evidence-Based Medicine Workshop Venue to be announced once finalized. |
July 21, 2023 (Friday), 1-5pm |
| Monthly Critical Appraisal of Topics Conferences to be gaciliated by Research Coordinators per Institution | Monthly Critical Appraisal of Topics Conferences per Institution |
| CAT Plenary/Liver Con Dates: September 23, 2023 December 16, 2023 March 2024 (During the JAC) Resumption of face-to-face Quarterly Critical Appraisal of Topics facilitated by the JRRE |
2 Clinical scenarios and articles are to be sent to institutions each on August 2023, November 2023, and February 2024; |
| Hybrid Research Workshop 4 week asynchronous via Moodle, followed by a 1 day on-site Onsite Workshop Research Protocol Presentation for Level I GI Fellows-In-Training - Research Protocol Presentation: August 12, 2023 - Research Forums of the Tripartite Societies |
Week 1: July 15-21, 2023 Week 2: July 22-28, 2023 Week 3: July 29-August 4, 2023 Week 4: August 5-11, 2023 |
| Research Manuscript Workshop for level II GI Fellows-In-Training | January 6, 2024 |