a 61-year - old male was admitted to the hospital with symptoms of progressive dyspnea and dizziness . he had a history of hypertension , diabetes mellitus , and angina . he had undergone right coronary artery stent insertion approximately six months previously . after his admission coronary angiography revealed a coronary artery fistula from the proximal left anterior descending coronary artery to the main pulmonary artery . the patient underwent mitral valve replacement , the cox - maze iii procedure , and external ligation of the coronary fistula . on the first postoperative day , he was also injected with enoxaparin subcutaneously together with warfarin until his prothrombin time ( pt)/international normalized ratio ( inr ) remained above 1.5 for a prolonged period . he had mild hyperbilirubinemia ( total bilirubin level , 2.66 mg / dl ) in the immediate postoperative period , his total bilirubin level gradually decreased , reaching a normal level on the fifth day after the operation . on the eighth day after the operation , his physical examination was significant for cold sweating with a body temperature of 37.6c , hypoactive bowel sounds , and epigastric tenderness . the significant laboratory findings were a hemoglobin level of 8.8 g / dl , thrombocytopenia with a platelet count of 74,000/mm , mild pt prolongation ( inr , 1.59 ) , and mild hyperbilirubinemia with a total bilirubin level of 2.64 mg / dl and a direct fraction of 2.20 mg / dl . other laboratory results were within normal limits , including hepatitis b and c viral markers as well as all indicators of underlying hepatobiliary diseases , such as previous gallbladder stones or liver cirrhosis . abdominal computed tomography imaging was performed , and contrast - enhanced scans showed a distended gallbladder with high - intensity sludge - like matter in the lumen ( fig . as soon as this diagnosis was made , anticoagulant medication was stopped , parenteral nutrition was initiated , and the patient was transferred to the hepatobiliary department in order to perform percutaneous transhepatic gall - bladder drainage ( ptgbd ) . after ten days of ptgbd and monitoring the color of the drainage , the drain output turned clear . on the same day , a repeat cholangiogram showed no evidence of ongoing bleeding , and most of the hematoma had resolved . during these ten days , the patient underwent anticoagulation with enoxaparin ( 200 mg of clexane twice a day ) . upon the resolution of hemobilia , he restarted warfarin and was discharged after the ptgbd was removed on postoperative day 28 . the term hemobilia was coined by sandblom in 1948 to describe hemorrhage into the biliary tract as a result of a communication or fistula between the biliary tract and the arteriovenous circulation . hemobilia is not a common complication , but urgent management is required to avoid complications such as gb perforation . several factors may cause gb hemorrhages , including biliary obstruction , acute and chronic cholecystitis , neoplasm , coagulopathy , and iatrogenic injury . recently , the most common cause of hemobilia has been reported to be trauma , with iatrogenic causes being the most important . the clinical manifestations of hemobilia , known as quincke s triad , consist of right upper quadrant abdominal pain , jaundice , and upper gastrointestinal tract hemorrhage . the etiology of the hemorrhage is thought to involve chronic inflammation of the gallbladder lumen . pathologic findings can include transmural inflammation of the gb wall , which can lead to infarction and erosion of the mucosa , in turn causing hemorrhage into the gallbladder lumen . while this patient was receiving anticoagulant therapy , bleeding from the lesion caused bile duct obstruction due to hemobilia . computed tomography scans may assist in the diagnosis of hemobilia , which has a characteristic finding of high attenuation within the gallbladder lumen with a layered fluid level presenting as blood or sludge . ultrasonography can be also a useful diagnostic tool , especially for patients with severe renal failure . warfarin interferes with the hepatic synthesis of vitamin k - dependent clotting factors ii , vii , ix , and x , resulting in their eventual depletion and prolongation of the clotting time , as measured by the pt and inr . triple antithrombotic therapy is indicated for atrial fibrillation patients undergoing stent insertion who are at a high risk for stroke ( chads2 risk score > 1 ) , but not for bleeding . since this patient s chads2 risk score was 2 and he did not have an elevated risk of bleeding , we considered triple antithrombotic therapy . in patients who undergo mitral valve replacement , we maintain the pt - inr in the range of 1.82.2 depending on the presence of atrial fibrillation . in the present case , we decided to maintain the inr level in the range of 1.61.8 because the patient received triple antithrombotic therapy for the intracoronary stent . while the patient was receiving anticoagulant therapy caused the bile duct obstruction , resulting in cholangitis and sepsis . therefore , gb hemorrhage , or hemobilia , should be considered in the differential diagnosis of all patients on anticoagulation therapy who present acutely with similar signs and symptoms . when bile flow is interrupted , the clot does not dissolve and remains in the bile duct due to disturbance of the fibrinolytic action of the bile . although minor cases of hemobilia can be managed with correction of the coagulopathy and hydration , hemobilia usually requires endoscopic therapy , radiologic intervention , or surgery . endoscopic retrograde cholangiography played a useful role in the management of hemobilia in this patient by removing the blood clot and sludge from the bile duct . in conclusion , for patients taking anticoagulant medications after cardiac surgery who show signs of anemia and acute abdominal pain ( especially in the right upper quadrant ) , hemobilia should be considered in the differential diagnosis , as this acute condition requires immediate additional evaluation and proper management .
anticoagulation therapy is essential after cardiac valve surgery . however 
 , spontaneous bleeding remains a major concern during anticoagulation therapy . 
 spontaneous gallbladder ( gb ) hemorrhage ( hemobilia ) is a rare occurrence during standard anticoagulation therapy . 
 this report presents a case of gb hemorrhage that occurred shortly after initiating oral anticoagulant therapy in a patient who had undergone mitral valve replacement surgery .