Biliary hemorrhage

　　The incidence of biliary hemorrhage in gastrointestinal diseases ranks fifth. The intervals and factors of onset in patients with biliary hemorrhage vary. The main cause is the formation of pathological fistula due to biliary injury and infection, with blood flowing into the duodenum through the bile duct. Patients are usually very curious about the causes of biliary hemorrhage. Below, we introduce the etiology and pathogenesis of biliary hemorrhage.

　　1. Biliary infection or calculus is the primary cause of biliary hemorrhage;

　　1. Biliary hemorrhage caused by injury is seen in liver trauma or sharp instrument injury. Stone extraction injury to the bile duct wall during AOSC surgery can cause intraoperative biliary hemorrhage. PTBD or U-shaped tube drainage of the hepatic bile duct can also cause biliary hemorrhage;

　　3. Other causes, such as hepatic aneurysms, liver cancer, etc.

　　Biliary hemorrhage is caused by pathological communication between intrapulmonary or extrapulmonary blood vessels and bile ducts due to various reasons. The blood flows into the duodenum through the bile ducts, resulting in upper gastrointestinal hemorrhage. Biliary hemorrhage is one of the main causes of upper gastrointestinal hemorrhage and is not uncommon in China. Common complications include:

　　1. Jaundice:1/4 to 1/3 of patients have jaundice, which is mostly obstructive jaundice. If fever is present at the same time, it often indicates biliary infection complicated with hemorrhage.

　　2. Enlargement of the liver and gallbladder:Patients with 50% to 60% of biliary hemorrhage may have liver and gallbladder enlargement and tenderness. After bleeding stops, blood clots are dissolved or excreted, and the enlarged liver and gallbladder may subsequently shrink.

　　Biliary bleeding is usually caused by communication between intrahepatic or extrahepatic arteries and veins and bile ducts or gallbladders, leading to upper gastrointestinal bleeding. So, what are the manifestations after biliary bleeding?

　　1. The patient may have fever, chills, jaundice, and epigastric colic followed by vomiting blood and black stools, accompanied by radiation pain in the shoulder and back.

　　2. After bleeding, the patient can stop bleeding spontaneously, and the above symptoms can be relieved.

　　3. Bleeding occurs once every week or so, with recurrence and periodicity.

　　4. During bleeding, a series of signs and symptoms of hemorrhagic shock may occur.

　　In addition, patients may also have these signs: signs of shock, anemia, and jaundice of the skin and sclera, epigastric tenderness, muscle tension, palpable liver and gallbladder enlargement with tenderness, active bowel sounds.

　　Biliary bleeding is of great concern due to its high complication rate and mortality rate. The key to improving the cure rate and reducing the mortality rate is to prevent biliary bleeding, and the main preventive measures include the following:

　　1. Diagnose and treat diseases such as biliary roundworm disease, gallbladder stone, liver tumor, liver hemangioma, etc. early.

　　2. Properly handle liver injury.

　　3. Use a fine needle for liver biopsy or PTC, and try to avoid repeated liver punctures.

　　4. PTCD should be performed at the periphery of the liver, and the integrity of the central hepatic tract cannot be damaged.

　　5. When performing surgery at the hilum or adjacent organs, avoid iatrogenic biliary bleeding.

　　5. Pay attention to biliary bleeding and deal with it early to prevent small amounts of biliary bleeding from developing into large-scale biliary bleeding.

　　Biliary bleeding is caused by large-scale bleeding in the biliary tract due to liver and gallbladder diseases, trauma, surgery, or systemic factors, and the following examinations need to be done:

　　1. Red blood cell and hemoglobin levels decrease, white blood cells and neutrophils increase, and occult blood in stool is positive. There are signs of obstructive jaundice.

　　2. B-ultrasound shows a hemorrhagic hematoma fluid area in the liver.

　　3. Radionuclide 198 gold scanning shows focal lesions in the liver.

　　4. Fiberoptic endoscopy can sometimes see biliary bleeding, and combined with barium meal examination, it can exclude ulcer disease and esophageal variceal bleeding.

　　5. Selective hepatic artery angiography can find the bleeding site; CT examination can show focal lesions; PTC, ERCP can sometimes assist in diagnosis.

　　A reasonable diet is the foundation for preventing and preventing the recurrence and aggravation of biliary bleeding. As a patient with biliary bleeding, one should always pay attention to the following points in diet:

　　1. Try to reduce the intake of fat, especially animal fat, do not eat fatty meat and fried foods, and as much as possible, replace animal oil with vegetable oil.

　　2. A considerable number of gallbladder inflammation and gallstone formation are indeed related to high cholesterol levels and metabolic disorders in the body, therefore, it is necessary to limit the consumption of high-cholesterol foods such as fish roe, yolks of various eggs, and the livers, kidneys, hearts, and brains of various carnivorous animals.

　　3. It is best to cook food by steaming, boiling, stewing, and braising, and it is strictly forbidden to consume large amounts of fried, fried, roasted, grilled, smoked, and salted foods.

　　4. Increase the intake of foods rich in high-quality protein and carbohydrates such as fish, lean meat, dairy products, fresh vegetables, and fruits to ensure heat supply, thereby promoting the formation of glycogen, and protecting the liver.

　　The treatment of biliary hemorrhage patients varies according to different causes of disease, as follows:

　　1. Traumatic Biliary Hemorrhage

　　Accurate localization is required. Under the conditions, the preferred method is percutaneous selective hepatic arteriography. Once the bleeding is found, the bleeding vessel can be blocked through the catheter, and immediate hemostasis can be achieved. In general, when there are conditions for selective hepatic arteriography and embolization, and there is a large amount of bleeding, surgical treatment should be performed. After controlling the blood flow into the liver, the liver hematoma is incised, the blood clots are removed, and the bleeding vessels are ligated; for deep hematoma, the hepatic segmental artery in the hepatic area can be ligated. When the hematoma is large and the wall is thick, partial liver resection or liver lobectomy along with the hematoma cavity can be performed.

　　2. Infectious Biliary Hemorrhage

　　(1) Percutaneous selective hepatic arteriography and embolization are the preferred treatment methods, especially for patients with severe illness and biliary hemorrhage after surgery, because in such cases, the risk of surgery is greater and the technical difficulty is also higher.

　　(2) For patients with infectious biliary hemorrhage, surgical treatment should be performed after a short period of preparation to treat biliary infection and control bleeding. The currently commonly used methods for controlling bleeding include: ①Ligation of the hepatic artery of the bleeding lobe or, when the定位征is not clear enough, ligation of the proper hepatic artery; ②Liver resection or partial hepatectomy. Through percutaneous selective hepatic arteriography, the site of bleeding can be understood, and at the same time, an embolization of the hepatic artery branch can be performed through arterial catheterization, but this method requires complex equipment and skilled technology, and cannot handle biliary lesions. Therefore, it is limited in use. For extrahepatic biliary hemorrhage, surgery can identify the source of bleeding. If the bleeding comes from the gallbladder, a cholecystectomy should be performed; if the bleeding comes from the hepatic artery, the ruptured hepatic artery branch should be resected or ligated, and the ulcer on the mucosal surface of the bile duct should be sutured simply, which generally cannot achieve the purpose of hemostasis, and the surgery may cause further bleeding. The biliary lesions should be treated simultaneously during surgery, and sufficient biliary drainage should be established to control infection.