嗜血杆菌是上消化道出血的不寻常但重要的原因。三分之二的胆道出血病例继发于侵入性肝胆胰手术。胆道血管发育不良异常,只报告了三例。在这里,我们报告了一个自主的80岁女性病例,5年前有胆囊切除术和心血管疾病-高血压病史,心力衰竭,急性心肌梗死,中风和非瓣膜性心房颤动,每天两次用阿哌沙班2.5毫克抗凝。自2019年7月以来,她有4次轻度至中度急性胆管炎发作,接受过广谱抗生素治疗和内镜逆行胰胆管造影术(ERCP),括约肌切开术和胆汁污泥提取。三个月后,患者出现了新的急性胆管炎发作,这次是胆道出血(Quincke\的三合会)。腹部CT血管造影显示没有活动性出血的证据,ERCP留下的塑料胆道假体。患者继续出现新的急性胆管炎伴胆道出血,其中一些与胰腺炎有关。使用SpyglassDSII进行了胆道镜检查,显示血管发育不良占据中部胆总管管腔围的一半,无活动性出血。在多学科会议后,考虑到高出血/血栓形成风险(CHA2DS2-VASc8),考虑关闭左心耳.然而,开始心血管干预的抗聚集方案后病情复发使其不可行.尝试了另一种使用超薄内窥镜进行氩等离子体凝固的胆道镜检查,没有成功。重复腹部CT血管造影,这次鉴定了胃十二指肠和胰腺下动脉的扩张分支。在用微线圈栓塞这些异常血管后,病人进展顺利,无复发出血或胆胰并发症。我们介绍一例梗阻性胆道出血伴多种胆胰并发症,继发于极为罕见的原因-胆总管血管发育不良。胆道镜检查在诊断和治疗指导中具有决定性作用。与胆道出血相关的诊断/治疗挑战脱颖而出,需要个性化和多学科的方法。
Haemobilia is an unusual but significant cause of upper gastrointestinal bleeding. Two-thirds of haemobilia cases are secondary to invasive hepato-biliopancreatic procedures. Biliary angiodysplasia is exceptionally unusual, with only three cases reported. Herein, we report the
case of an autonomous 80-year-old woman with a history of cholecystectomy 5 years ago and cardiovascular disease-hypertension, heart failure, acute myocardial infarction, stroke and non-valvular atrial fibrillation, anticoagulated with apixaban 2.5 mg two times per day. Since July 2019, she had four episodes of acute cholangitis of mild-to-moderate severity, having undergone broad spectrum antibiotics treatment and endoscopic retrograde cholangiopancreatography (ERCP), with sphincterotomy and bile sludge extraction. After 3 months, the patient presented with a new episode of acute cholangitis, this time with haemobilia (Quincke\'s triad). An abdominal CT angiography showed no evidence of active bleeding, with plastic biliary prosthesis left by ERCP. The patient continued presenting new episodes of acute cholangitis with haemobilia, some of them with associated pancreatitis. A cholangioscopy with Spyglass DS II was performed, showing an angiodysplasia occupying half of the luminal circumference of the middle choledoccus, without active haemorrhage. After a multidisciplinary meeting and given the high haemorrhagic/thrombotic risk (CHA2DS2-VASc 8), closure of the left atrial appendage was considered. However, relapse of the condition after beginning the antiaggregation protocol for cardiovascular intervention made it unfeasible. Another cholangioscopy with an ultra-thin endoscope for argon-plasma coagulation was attempted, without success. The abdominal CT angiography was repeated, this time with identification of dilated ramifications of the gastroduodenal and inferior pancreatic arteries. After embolisation of these aberrant vessels with microcoils, the patient went well, with no recurrence of bleeding or biliopancreatic complications. We present a
case of obstructive haemobilia with multiple biliopancreatic complications, secondary to an extremely rare cause-choledochal angiodysplasia. Cholangioscopy had a decisive role in the diagnosis and therapeutic guidance. The diagnostic/therapeutic challenge associated with haemobilia stands out, with the need for a personalised and multidisciplinary approach.