# Bloody Phenomenon: A Rare Case of Hemobilia From Cystic Artery Hemorrhage Following Percutaneous Cholecystostomy

## TL;DR

This paper presents a rare case of hemobilia caused by cystic artery hemorrhage after a percutaneous cholecystostomy, highlighting the importance of early diagnosis and multidisciplinary treatment.

## Contribution

The paper adds a rare clinical case of hemobilia following percutaneous cholecystostomy and emphasizes the need for prompt imaging and surgical intervention.

## Key findings

- Hemobilia can present with sanguineous cholecystostomy drainage without classic symptoms.
- CT angiography is effective in identifying active cystic artery hemorrhage.
- Successful treatment involved angiographic stent placement and subsequent cholecystectomy.

## Abstract

Hemobilia, defined as bleeding into the biliary tract, is a rare but potentially life-threatening condition. It most commonly results from trauma, malignancy, or iatrogenic interventions; however, its clinical presentation is often atypical and frequently lacks the classic Quincke's triad, making the diagnosis challenging and potentially leading to delays in management and treatment. With the increasing use of percutaneous cholecystostomy in high-risk patients with cholecystitis, there is a growing recognition of vascular complications such as cystic artery hemorrhage.

We describe the case of a 72-year-old male with a complex cardiovascular and metabolic history who presented with sanguineous drainage from a percutaneous cholecystostomy tube, three weeks after undergoing endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct (CBD) stone removal and biliary stent placement. He had developed a perihepatic collection requiring cholecystostomy during his prior hospitalization. On re-presentation, he exhibited mild abdominal tenderness, leukocytosis, anemia, and hypoglycemia. CT angiography revealed active extravasation from a branch of the cystic artery and a displaced CBD stent. The patient underwent a successful angiogram with placement of a covered stent in the right replaced hepatic artery. He was managed in the intensive care unit with broad-spectrum antibiotics, bowel rest, glycemic control, and supportive care. Following clinical improvement, he was discharged to a rehabilitation center with plans for elective cholecystectomy and stent reassessment.

This case discusses the importance of recognizing hemobilia as a rare but serious and possible complication of percutaneous biliary drainage. Cystic artery hemorrhage may arise from mechanical trauma, inflammatory vascular erosion, stent migration, anatomical variations, or infection. Timely imaging and intervention, particularly via angiography, are essential for hemodynamic stabilization. Definitive management with cholecystectomy is key to preventing recurrence and further complications that may arise.

Clinicians should consider and maintain a high index of suspicion for hemobilia in patients presenting with bloody cholecystostomy output, even in the absence of classic signs such as gastrointestinal bleeding. Prompt imaging, multidisciplinary management, and definitive surgical management such as cholecystectomy are essential for preventing recurrence and further complications, thereby improving overall patient outcomes.