A massive upper gastrointestinal bleeding was seen on the second day of admission. After stabilization of general condition of patient by supportive therapy for pancreatitis, she went to operation. It was found that the bleeding was secondary to a gallbladder polyp and cholecystectomy was performed. She had an uneventful postoperative period and discharged from the hospital on the postoperative 14th day.

As a conclusion, a gallbladder polyp can rarely be a cause of massive upper gastrointestinal bleeding and subsequent pancreatitis.©2008, Firat University, Medical Faculty

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.

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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.

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Figure 2: The histopathological aspect of gallbladder polyp.

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.

1) Bazzoni C, Serini M, Ongari M, Sguazzini C, Alleva M, Lombardi C. Massive hemobilia caused by necrotic hemorrhagic cholecystitis. Report of a case. Minerva Chir 1993; 48: 857-860.

2) Ellington RT, Seidel RH, Burdick JS, Peterson WL, Harford WV. Acalculous cholecystitis presenting as hemobilia and jaundice. Gastrointest Endosc 2000; 51: 218-220.

3) Eric SS, Kim R. Geisinger: Case of the day 3. Diagnosis: hemobilia: İntraluminal gallbladder hematoma. J Ultrasound Med 1993; 4: 240-249.

4) Yi Xue Za Zhi Kuo CM, Kuo CH. Changchien CS.Sequential sonographic changes of the gallbladder in hemobilia: case report of a patient with intrahepatic duct stones. Changgeng 1999; 22:541-545.

5) Cappell MS, Marks M, Kirschenbaum H.Massive hemobilia and acalculous cholecystitis due to benign gallbladder polyp.Dig Dis Sci 1993; 38: 1156-1161.

6) van Dijk LC, Beishuizen A, Bronsveld W, van Dijk HA.Hemobilia, a rare and difficult diagnosis. Ned Tijdschr Geneeskd 1991; 135: 901-904.

7) Adam R, Fabiani B, Bismuth H.Hematobilia resulting from heterotopic stomach in the gallbladder neck. Surgery 1989; 105: 564-569.

8) Coelho JC, Bonin EA, da Costa MA, da Cunha AG, Sartor MA. Acute cholecystitis secondary to hemobilia after percutaneous liver biopsy. Dig Surg 2001; 18: 227-229.

9) Jaeger M, Willimann P. Spontaneous hemobilia in the differential diagnosis of upper gastrointestinal hemorrhages. Schweiz Med Wochenschr 1976; 106: 1392-1395.