Background : Haemobilia, or bleeding into the biliary tree, is rare. Most haemobilia occurs secondary to percutaneous liver procedures. Uncommonly, haemobilia can present with cholangitis or cholecystitis secondary to biliary obstruction from clots. Thrombolytics, such as alteplase, are used to flush selected venous access tubing to maintain patency, as well as in pulmonary emboli to break down clots. Resolution of biliary clots following alteplase and saline flushes has been described rarely in the literature.

Methods : The patient consented to this case report. We include radiological images.

Results : An 87-year-old male was admitted with acute cholecystitis and an Escherichia Coli bacteremia on the background of chronic obstructive pulmonary disease, pulmonary hypertension, ischaemic heart disease, mitral stenosis, and chronic kidney disease. His surgical history includes a partial pancreatectomy and gastrojejunostomy. He was treated with intravenous antibiotics and a percutaneous cholecystostomy. He developed atrial fibrillation and subsequently was begun on warfarin. He re-presented five days after discharge with fevers, abdominal pain, deranged liver function tests, supratherapeutic INR, and a computed tomography scan suggestive of cholecystitis and biliary obstruction secondary to haemobilia and biliary clots. He was managed with IV antibiotics, vitamin K, and an alteplase flush through the percutaneous cholecystostomy. The patient improved clinically and a cholangiogram demonstrated dissolution of the biliary clots.

Conclusions : Biliary clots are usually managed endoscopically. However, due to altered anatomy and comorbidities, an alteplase flush was trialed. Alteplase flush may be a second line treatment to relieve obstruction from biliary clots.