Hemobilia, bleeding through biliary tract, is an uncommon cause of hematemesis and/or melena. Moreover gallbladder diseases constitute the rarest causes of hemobilia. No such a case of hemobilia associated with gallbladder ulcer has been reported as far as we could find. This paper is to report a rare case of ours who had hemobilia associated with ulcerative disease of gallbldder and was treated in Presbyterian Medical Center in Chonju, Korea.
A 29 year old G 4 P 4 L 3 housewife was admitted to the Department of Internal Medicine of P.M.C. on May 3, 1965 complaining of right upper abdominal pain, hematermesis and melena for 2 weeks intermittently prior to admission. She had had frequent indigestion and epigastric hunger burning pain for 6-7 years previously and had had irregular treatment with drugs without imporvement. She denied any previous episode of jaundice, colicky pain, allergy or raw river fish ingestion. At the time of admission she was slight dyspneic and severely anemic. On physical examination B.P. was 130/70 mm. Hg., pulse rate 96/min., B.T. 99´F. conjunctiva very pale.
Sclera was not icteric. There was mod. tenderness in right hypochondriac region and 2 F. B. liver was palpable. Rectal examination showed brownish dark soft stool in rectum. On admission Hgb. was 4.3 gm.%, Htc. 16%, W. B. C. 12,950/cu. mm. with normal differential count. Stool revealed positive occult blood, trichuriasis and ankylostomiasis. Urinalysis ans Widal test were normal. Bolld indices showed normocytic hypochromic anemia. Sigmoidoscopy showed no gross abnormality. chest x-ray, esophagogram, upper GI fluoroscopy and barium enema gave normal finding. She was treated under presumptive diagnosis of bleeding peptic ulcer. During the first hospitalization no gross hematemesis or melena was noted. She was discharged on sixth hospital day well recovered.
On may 12, 1965 she was admitted again to the same department with chief complaint of recurrent hematemesis, melena and R.U.Q. pain. She experienced massive melena, hematemesis and R.U.Q. pain on three different occasions after discharge. On the second admission physical examination was same was those of first admission except icteric sclera and grade I systolic murmur at heart apex. Laboratory data revealed severe anemia, leukocytosis, neutrophilia and elevated serum bilirubin. After admission massive hematemesis, melena and severe R. U. Q. pain developed. Repeated esophagogram and upper GI fluoroscopy showed no intrinsic abnormality. Exploratory laparotomy demonstrated about 1.3×0.6 cm. sized ulcer in anterior wall of fundus of the gallbladder. The cystic duct was anomalously long and opened into distal common bile duct very close to ampulla of Vater. Cholecystectomy was performed.
Histopathologically sections of the resected gallbladder showed an ulcer bed which was elevated and largely made up of granulation tissue having active fibroblastic proliferation. The ulcer lesion was infiltrated with PMNs. It also revealed evidence of active hemorrhage. There was occasional brownish pigmentation noted. The muscular layer beneath the ulcer was completely destroyed. The serosa was intact. The rest of the mucosa was quite well preserved.
Postoperative hemobilias developed in two separated occasions (postop. 10 th day and postop. 5th week), and conservative treatments were tried resulting in effect. No operation was performed for postoperative hemobilia. Periodic examination of the patient for 12 months up to the present showed no clinical evidence of recurrence of the disease resulting in clinical cure.
|