Hemobilia is defined as a hemorrhage of the gastrointestinal tract due to the communication of blood vessels with the intra and extra-hepatic biliary tract and rarely to the branches of the cystic artery within the gallbladder wall¹. Gallbladder polyps and massive upper gastrointestinal bleeding due to hemobilia are very rare cases^2-5. Clots due to hemobilia can cause cholecystitis and pancreatitis by obstructing the biliary tract tree².

Fifty eight years old woman was admitted to our emergency department complaining with an epigastric and right upper quadrant abdominal pain. Severity was increased at last 4-5 days of 15 days. There is no any clinical finding and symptom apart from jaundice, right upper quadrant and epigastric abdominal pain and tenderness. There were marked leukocytosis (15000/m3), increased amylase (450 IU/dl), lipase (189 IU/dl), total bilirubin (6 mg/dl) and direct bilirubin levels (2.5 mg/dl). On abdominal ultrasound (US) examination, choledoc was 10mm in diameter and was containing multiple milimetric calcules and dense bile sludge. Thickness of the gallbladder wall was 5mm. There were multiple calcules in the gallbladder of which the largest one was 14mm in diameter. There was a solid hypoecoic mass which was 15mm in diameter at the pancreatic head localization. By these findings, she hospitalized with the diagnosis of biliary pancreatitis and medical treatment has begun.

On the second day of admission, a massive upper gastrointestinal bleeding was occurred. Immediately upper gastrointestinal endoscopy was performed after hemodynamic stabilization of the patient by three units of eritrocyte suspension transfusion. Appearance of the mucosa of esophagus and stomach were revealed as normal. Duodenum was filled with fresh blood. At the same session Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was also performed. Active bleeding through the duodenal papilla, distortion of pancreatic canal and multiple filling defects in common bile duct has been observed. The procedure completed with a sphincterotomy. She underwent an elective laparatomy. During laparatomy a mass was detected in the pancreatic head with a 3x2x2 cm in size on palpation. Frozen section biopsy was evaluated as pancreatitis. Bloody gallbladder fluid has come through transvesical aspiration canule. Cholecystectomy was performed and gallbladder was completely filled with hematoma (Figure 1). On the anterior wall of the gallbladder, there was a polipoid ulcerative mass 1.5x1.5x0.5cm in size with which some clotted blood but not active bleeding over on it. Pathological diagnosis of this polyp was revealed as benign. No stone was seen in gallbladder and common bile duct. Transduodenal sphincterotomy was performed.

Figure 1: hematoma with which completely filled the gallbladder

Histopathological examination of the specimen revealed as hemorrhagic and necrotic polyp in gallbladder wall (Figure 2). She discharged from the hospital with an uneventful postoperative course on postoperative 14^th day.

Figure 2: The histopathological aspect of gallbladder polyp.

Hemobilia, i.e. blood loss via the bile ducts, is a rare disorder, which may be caused by trauma, vascular disorders, gallstones, infection and inflammation, tumors and coagulation disorders, hemorrhagic cholecystitis, heterotropic stomach and benign gallbladder polyp^1,5-8. Hemobilia is seen as 55% traumatic (surgical causes such as; liver biopsy and surgery,and nonsurgical causes) and 45% nontraumatic^1,6. Tumors are the rare causes of hemobilia^1,6.

Hemobilia may cause morbidity and mortality. Important symptoms are gastrointestinal bleeding, jaundice and colicy abdominal pain in the right upper abdominal quadrant. Gastroduodenoscopy, US, ERCP, Computerized Tomography (CT) may be used to obtain additional information when hemobilia is suspected. As also seen in our case ultrasonography can be misdiagnose in differentiating the gallbladder stones and clots in it. Magnetic Resonance Image (MRI) and selective angiography may provide detailed information of the bleeding, but are less appropriate as an initial screening method^3,6,9.

Hemobilia due to galbladder polyps are rare pathologies⁵. Clots due to hemobilia can cause jaundice and pancreatitis by obstructing the biliary tract². Massive hemobilia, massive upper gastrointestinal bleeding and pancreatitis due to the polyps are very rare. In our case, pancreatitis has been diagnosed by patient complaints, physical examination and laboratory findings., Esophagogastroduodenoscopy was performed after upper gastrointestinal bleeding. While esophagus and stomach were normal, duodenum was full of blood.

At the same session ERCP was performed. Active bleeding from duodenal papilla, distortion of pancreatic canal and multiple filling defects in common bile duct has been observed. The procedure finished with papillotomy. As there is a displacement in pancreatic canal on ERCP and a pancreatic mass was seen on US, we had a suspicion of pancreatic tumor. We interpreted that the pancreatic tumor caused the hemobilia by invading pancreatic canal. Curative surgery decision was made. Laparotomy was performed after the improvement of clinical pancreatitis. It was observed that this was secondary to the gallbladder polyp.

In conclusion; benign gallbladder polyps can be a reason of hemobilia causing massive upper gastrointestinal bleeding and pancreatitis. We concluded that it can be completely cured by cholecystectomy.