When bleeding occurs in the biliary tract, the blood may either drain directly to the intestine or it may partially clot within the tract. The resulting clots generally cause clinical symptoms [1]. In a series of 355 cases worldwide [2] the most frequent of these symptoms was biliary colic (70%) and 60% of the patients had jaundice. In haemobilia, the formation of clots can be clearly influenced by the character of the haemorrhage – whether it is profuse or slight, prolonged or of short duration, continuous or a single or repeated episode. Once formed, the clots may dissolve and pass into the intestine or remain in the biliary tract.

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Figure 1. Postoperative cholangiography.

We present a patient with persistent clots in the main bile duct after surgery for cholangitis. The clots eventually disappeared due to the fibrinolytic effect of bile [3], which has been shown in vitro to be four times greater when the clots contain bile. The results in our patient (clot dissolution due to continuous contact with bile after pinching the drainage tubes) support this observation and may be an interesting therapeutic option in patients with bile duct obstruction due to clots.

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Figure 2. Postoperative cholangiography after treatment with heparin lavage via the Kehr tube.

The patient was a 68-year-old man with a history of type 2 diabetes mellitus, mitral stenosis and an emboligenic stroke with residual hemiparesis. He had a St Jude mitral valve prosthesis and was receiving oral anticoagulation agents. He presented with symptoms of acute lithiasic cholangitis. He underwent cholecystectomy with intraoperative cholangiography (numerous calculi in the bile duct), choledochorrhaphy, removal of the stones and closure over a Kehr tube.

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Figure 3. Postoperative cholangiography after five weeks treatment.

The jaundice continued during the postoperative period and a new cholangiography (Fig. 1) showed a filling defect in the common bile duct (a clot). Treatment was started with heparin lavage via the Kehr tube, and another cholangiographic examination (Fig. 2) showed complete occupation of the bile duct, which coincided with symptoms of haemobilia. The systemic anticoagulation therapy was reduced and arteriographic control showed no sign of bleeding. Decompression of the bile duct was later performed by percutaneous transhepatic cholangio-pancreatography and an external tube placed. Due to the persistence of the symptoms and colangiographic occupation of the bile duct (Fig. 3) after five weeks treatment both drainage tubes (Kehr and percutaneous) were pinched to make use of the fibrinolytic effect of bile and encourage continuous contact of the bile with the clots in order to dissolve these. The patient recovered and the jaundice disappeared. A control cholangiography showed a good passage to the duodenum with no filling defects (Fig.4). A control scintiscan showed no signs of haemorrhage.

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Figure 4. Control cholangiography showed a good passage to the duodenum with no filling defects.

Bleeding is relatively common in the biliary tract after such manoeuvres as transparietohepatic cholangiography or surgical exploration of the common bile duct, especially in certain risk groups, for example persons with cirrhosis, chronic bile duct infection, coagulation disorders, or those receiving oral anticoagulation therapy [4].

The properties of clots in the biliary tract were studied by Sandblom et al. [5], who showed that the blood can coagulate partially or completely at this site. These clots in the biliary tract may also become stones [6]. The brown colour of these clots indicates that they are impregnated with bile. The fibrinolytic effect of bile in man and several species of mammals is well known [6, 7]. However, this effect is not always beneficial, as it is the main cause of slow recovery of lesions to the hepatic parenchyma. The fibrinolytic activity of bile has been demonstrated in vitro with techniques of ammonium sulphate, acetone and chloroform-methanol [8], showing that in these cases the fibrinolytic power of bile is four times greater. This effect depends on the time during which the clot and the bile are in contact; when the bile is in continuous contact with the clot, this dissolves in 24 hours; however when the flow of bile is intermittent the clot remains intact. Some authors [8] mention a protein found in bile called fibrinolysin, whose main function is not related with fibrinolysis, which is just a secondary effect. It could also be an analogue of the fibrinolysis activators found in most small ducts in the body, such as capillaries, venules, urinary tract, breast ducts and tear ducts.

The persistence of the clots can normally be explained by interruption in the flow of bile. When a drainage in the bile duct is left open for some time, a clot may form below the drainage point and remain intact [5].

Biliary obstruction secondary to haemobilia occurs in a few patients who have biliary tract haemorrhage. In cases of profuse haemobilia there is an uninterrupted flow of mixed blood and bile towards the intestine, due to the fibrinolytic effect of bile. However, in small haemorrhages deposits of blood may form in the biliary tract, due to the difference in gravity between bile and blood [9], with the consequent formation of clots. Profuse bleeding in the biliary tract therefore produces clots of mixed blood and bile, whereas small haemorrhages produce clots of pure blood. Most clots in the biliary tract are lysed or expelled spontaneously within 24-48 hours [9], although they sometimes remain in the biliary tract [9], resembling stones, with which they may be confused. In fact, they occasionally become stones, and may produce obstructive jaundice [10, 11] or cholecystitis [11, 12]. The presence of clots should be suspected in patients at risk of bleeding who have filling defects on postoperative cholangiography.

If the clots produce obstructive jaundice or biliary colic, biliary decompression is indicated by endoscopic sphincterotomy, percutaneous transhepatic cholangio-pancreatography [13, 14] or the use of fibrinolytic agents [15]. The flow of bile is able to dissolve the clots in the biliary tract [16], but these remain intact if they are protected from the bile. The formation of clots can be prevented by avoiding haemorrhage, but if they do form dissolution can be stimulated by restoring the flow of bile. The patient reported here is a clear example of this. The clots persisted, resembled stones and were finally dissolved by encouraging continuous contact with the bile, which we achieved by closing the drainage tubes.

As bile has a marked fibrinolytic effect it is important to maintain the flow of bile during the immediate postoperative period, for example by clamping the Kehr tube as soon as possible, in patients at high risk for haemobilia undergoing bile duct surgery.