S3456 Hemobilia Presenting as Hematemesis in Acute Cholecystitis: A Rare Gastrointestinal Bleed

Introduction: Hemobilia is relatively rare as a cause of gastrointestinal bleeds, and it usually presents itself as biliary colic. Most often it is caused by trauma from iatrogenic sources such as endoscopic retrograde cholangiopancreatography (ERCP) or surgery. Less commonly, it can be caused by hepatic or biliary malignancies. In a small percentage of cases, cholecystitis alone causes hemobilia. Laboratory evaluation in cholecystitis is typically a hepatocellular pattern of injury. Rarely is acute cholecystitis without choledocolithiasis documented with both hepatocellular and cholestatic patterns of injury. This case serves as a rare presentation of hemobilia, acute cholecystitis, and a mixed pattern of liver injury. Case Description/Methods: A 70-year-old woman presented with a syncopal event after 3 days of vomiting, diarrhea and abdominal pain. Noted episodic events of dark stools and blood in emesis. On arrival, she was pale, hypotensive to 80/46, tachycardic to 110s. Was appropriately resuscitated with intravenous fluids, blood products and started on intravenous protonix. Had a witnessed episode of hematemesis. Computed tomography angiography (CTA) of the abdomen showed an enlarged gallbladder with a thickened wall and multiple lamellated gallstones without biliary ductal dilatation. An abdominal ultrasound showed a partially distended gallbladder containing base intraluminal sludge/debris and shadowing stones. Esophagoduodenoscopy (EGD) showed red blood in duodenal bulb and second portion of the duodenum, with a blood clot visualized on the ampulla of Vater with some active oozing which raised suspicions for malignancy. MRCP showed a 2.5 cm gallbladder polyp. Pathology after robotic cholecystectomy showed grossly polypoid tissue protrusion into the gallbladder lumen with necrotic tissue, acute inflammation, and blot clot with no evidence of malignancy. The patient was discharged and 2 months after her discharge her liver function tests normalized. Discussion: This case highlights a nonmalignant cause of hemobilia and importance of keeping on differential in cases of unclear sources of injury.