Hemobilia: Historical overview, clinical update, and current practices

Acute Pancreatitis Caused by Hemobilia: An Unusual Complication of Laparoscopic Cholecystectomy in a Patient With History of ROUX-EN-Y Gastric Bypass

Acute pancreatitis as a result of hemobilia after laparoscopic cholecystectomy is a rare vascular complication with a challenging clinical diagnosis and treatment approach not eminent or available. We are reporting the fourth case of acute pancreatitis after laparoscopic cholecystectomy caused by hemobilia secondary to a right hepatic artery pseudoaneurysm. To our knowledge, this is the first such case reported in the United States.

Endoscopic hemostasis with a self-expandable metal stent as bridge therapy for hemobilia

Background and study aims

Management of hemobilia is often challenging. Recently, endoscopic hemostasis with a self-expandable metal stent (SEMS) has shown promising efficacy for controlling bleeding at the endoscopic sphincterotomy site. This study aimed to assess efficacy and feasibility of endoscopic hemostasis as bridge therapy for hemobilia.

Patients and methods

Patients with hemobilia between 2008 and 2023 were retrospectively reviewed. We compared efficacy of hemostasis between the initial endoscopic hemostasis group (ENDO group) and the initial angiographic embolization group (EMBO group). The primary outcome was initial hemostasis success rate and the secondary outcomes were delayed bleeding rate, subsequent embolization rate, 28-day mortality, transfusion amount, time to first hemostasis, total hemobilia time, and incidence of hypovolemic shock.

Results

A total of 26 patients with hemobilia were included in this study and 17 patients (65.4%) were identified as the ENDO group and nine patients (34.6%) were classified as the EMBO group. The success rate of initial hemostasis was 88.2% (15/17) in the ENDO group and 100% (9/9) in the EMBO group ( P = 0.529). The rate of delayed bleeding in the ENDO group was 17.6% (3/17) and 0.0% (0/9) in the EMBO group ( P = 0.529). Total hemobilia time was shorter in the ENDO group than in the EMBO group (mean: 281.5 ± 1022.4 minutes vs. 5002.8 ± 7982.6 minutes; P < 0.001) Stent insertion depth was associated with successful hemostasis without delayed bleeding. ( P = 0.015).

Conclusions

Endoscopic hemostasis using SEMS for hemobilia appeared to be a feasible bridge therapy.

Radiological diagnosis and management of postlaparoscopic cholecystectomy right hepatic arterial pseudoaneurysm: A case report

Injuries to blood vessels occur in 0.8% of the cases following laparoscopic cholecystectomy. They may result from direct penetration while insertion of trocar or by thermal injury (electrocautery). Pseudoaneurysm of hepatic artery is a rare occurrence. It is a serious complication following acute or chronic injuries to hepatic artery, with only 0.06% to 0.6% of the cases being reported. Endovascular embolization is usually the first line treatment in the management of pseudoaneurysm of hepatic artery with high success rate. Surgical intervention should be considered if the embolization fails, pseudoaneurysm are infected or other vascular structures are compressed. Our case highlights a 48-year-old male presenting with complaints of pain abdomen and jaundice later diagnosed to be a case of pseudoaneurysm of right hepatic artery and was successfully managed with angiographic embolization, which is the first line of management.

Hemobilia: A Narrative Review of Current Diagnostic Techniques and Emerging Management Strategies

Hemobilia is a relatively uncommon but important cause of gastrointestinal bleeding. It occurs due to abnormal communications between the biliary system and surrounding vasculature, often caused by surgical interventions, trauma, infections, or malignancies. The rise of advanced hepato-pancreato-biliary techniques, including radiofrequency ablation and transjugular intrahepatic portosystemic shunt (TIPS) placement, necessitates careful evaluation for the potential presence of hemobilia during the post-procedural period of these patients. Hemobilia can be difficult to diagnose, as common symptoms like jaundice, abdominal pain, and gastrointestinal bleeding are not always present together. Imaging techniques such as Doppler ultrasound, contrast-enhanced computed tomography (CT), and angiography are critical for identifying the source of bleeding. Treatment typically focuses on achieving hemostasis and ensuring proper bile flow, with options including endoscopic techniques, angiography with transcatheter arterial embolization, and, in severe cases, surgical intervention. This review highlights recent advances in diagnostic and therapeutic approaches, emphasizing the need for early recognition and tailored interventions to improve patient outcomes.

Recurrent hemobilia secondary to extrahepatic biliary tract cholangiocarcinoma. A diagnostic challenge

The etiology of hemobilia has mainly iatrogenic (>50%), followed by traumatic causes. Others are biliopathy due to portal high pressure, or neoplastic or infective biliopathy. In the case of non-clear hemobilia, direct-vision-cholangioscopy can change the management in >34% of cases. Our patient had episodes of obstructive hemobilia with secondary cholangitis without objectifying underlying pathology. When she was referred to our center, SpyGlass®-cholangioscopy identified the suspicious lesion compatible with early-stage cholangiocarcinoma despite the diagnostic delay. In conclusion, it is important to keep in mind the neoformative etiology as a potential cause of hemobilia of unclear origin, in which case, cholangioscopy (SpyGlass®) can contribute to the recognition of the signs of malignancy of the lesion and, therefore, to the diagnosis.

Non-Traumatic Hepatobiliary Emergencies

Hepatobiliary emergencies typically present with a constellation of different symptoms including abdominal pain, fevers, nausea, vomiting, jaundice, coagulopathy, and in some instances, encephalopathy. The differential can be broad and may include infectious, inflammatory, and even iatrogenic etiologies. Workup with appropriate lab and imaging studies can help discern between different pathologies and thus guide their management. Interventions can range broadly from conservative management with medical therapy to endoscopic options or surgery. This article explores the diagnostic workup and evaluation as well as the current therapeutic interventions for a variety of these nontraumatic hepatobiliary emergencies based on the most current literature.

Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.

Case report: Recurrent hemobilia due to hepatic artery pseudoaneurysm mimicking gastrointestinal tract bleeding

Hemobilia, a rare form of upper gastrointestinal bleeding (UGIB), is a potentially fatal complication that usually occurs after iatrogenic hepatobiliary trauma. However, hemobilia is clinically challenging to diagnose and often gets too late to diagnose. We herein report a case of recurrent hemobilia due to hepatic artery pseudoaneurysm (HAP) that was initially misdiagnosed as gastrointestinal tract bleeding. However, the patient was treated successfully with percutaneous coil occlusion of the pseudoaneurysm. This case illustrates that hemobilia can present as a mimic of gastrointestinal tract bleeding, but this is often difficult to diagnose at first glance and often misleads clinicians, especially emergency physicians, into making an incorrect diagnosis. Familiarity with the clinical features of hemobilia can help raise clinical suspicion and facilitate the early diagnosis and treatment of hemobilia.

Precordial pain caused by a hemocholecyst due to gallbladder cancer: A case report

INTRODUCTION AND IMPORTANCE

A hemocholecyst refers to hemorrhage originating from and confined to the gallbladder. Intraluminal hemorrhage of the gallbladder is a rare symptom of gallbladder cancer (GBC), which can cause hemorrhagic cholecystitis. The symptoms of hemorrhagic cholecystitis are similar to those of classic acute cholecystitis where precordial pain is atypical. Here, we report a case of a precordial pain-inducing hemocholecyst due to GBC.

CASE PRESENTATION

An 86-year-old woman was admitted to the emergency department due to persistent, sudden-onset precordial pain. Electrocardiogram (ECG) findings and cardiac enzyme levels were normal; however, severe anemia (hemoglobin 6.4 g/dL) was noted. Computed tomography (CT) showed a tense gallbladder with a heterogeneous, high-density area. Contrast-enhanced CT did not reveal contrast extravasation or obvious mass lesions. Considering the risk of hemorrhagic cholecystitis, we performed laparoscopic cholecystectomy. Operative findings were normal, however, the gallbladder lumen was filled with blood clots, while the gallbladder body had a papillary, infiltrating-type lesion.

CLINICAL DISCUSSION

Histopathological examination confirmed the diagnosis of moderately differentiated gallbladder adenocarcinoma. The precordial pain disappeared postoperatively. Due to the patient's age and general condition, no additional gallbladder bed resection or S4/5 hepatic bisegmentectomy and lymphadenectomy were performed.

CONCLUSION

A hemocholecyst can cause precordial pain; therefore, abdominal imaging may be useful for diagnosing patients with nonspecific precordial pain. In addition, GBC should be considered as a potential cause of hemocholecysts. Early diagnosis and urgent cholecystectomy should be performed to prevent gallbladder perforation in patients with hemocholecysts.

Endovascular and Endoscopic Treatment of Hemobilia: A Report of Two Cases

Hemobilia is a term used to describe bleeding caused by abnormal communication between blood vessels and bile ducts. Some vascular anomalies, such as aneurysms or arterio-biliary fistulas, facilitate the appearance of this type of biliary bleeding. Other causes have been described such as iatrogenic causes secondary to percutaneous procedures, infections, tumors, and trauma. We report two cases of hemobilia. The first one presented with acute biliary bleeding with secondary hypovolemic shock. Bleeding was controlled after percutaneous interventions with a selective embolization technique. The second case was a patient who presented to the emergency department after a fall from his height. During hospitalization, acute cholangitis was documented, associated with hemobilia. A wide papillotomy and biliary duct instrumentation were done with the extraction of a large blood clot. Angiography is the standard for diagnosis and embolization becomes the best tool for the detection and control of vascular abnormalities that can perpetuate bleeding.

Covered TIPS Procedure-Related Major Complications: Incidence, Management and Outcome From a Single Center

BACKGROUND AND OBJECTIVE

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure for treating complications of portal hypertension. Due to the complexity of anatomy and difficulty of the puncture technique, the procedure itself might brought potential complications, such as puncture failure, bleeding, infection, and, rarely, death. The aim of this study is to explore the incidence, management, and outcome of TIPS procedure-related major complications using covered stents.

METHODS

Patients who underwent TIPS implantation from January 2015 to December 2020 were recruited retrospectively. Major complications after TIPS were screened and analyzed.

RESULTS

Nine hundred and forty-eight patients underwent the TIPS procedure with 95.1% (n = 902) technical success in our department. TIPS procedure-related major complications occurred in 30 (3.2%) patients, including hemobilia (n = 13; 1.37%), hemoperitoneum (n = 7; 0.74%), accelerated liver failure (n = 6; 0.63%), and rapidly progressive organ failure (n = 4; 0.42%). Among them, 8 patients died because of hemobilia (n = 1), accelerated liver failure (n = 4), and rapidly progressive organ failure (n = 3).

CONCLUSION

The incidence of major complications related to TIPS procedure is relatively low, and some of them could recover through effective medical intervention. In our cohort, the overall incidence is about 3%, which causes 0.84% death. The most fatal complication is organ failure and hemobilia.

Multidetector Computed Tomography (MDCT) Findings of Complications of Acute Cholecystitis. A Pictorial Essay

Acute cholecystitis stands out as one of the most common surgical pathologies that should always be considered in a right-upper abdominal pain emergency. For this, the importance of a correct diagnosis is well described. However, it has been demonstrated that the simple combination of clinical (pain, Murphy’s sign) and laboratory (leukocytosis) parameters alone does not provide for ruling in or ruling out the diagnosis of this condition, unless accompanied by a radiological exam. For a long time, and still today, ultrasonography (US) is by far the first-to-proceed radiologic exam to perform, thanks to its rapidity and very high sensibility and specificity for the diagnosis of simple acute cholecystitis. However, acute cholecystitis can undergo some complications that US struggles to find. In addition to that, studies suggest that multidetector computed tomography (MDCT) is superior in showing complicated forms of cholecystitis in relation to sensibility and specificity and for its capability of reformatting multiplanar (MPR) reconstructions that give a more detailed view of complications. They have shown to be useful for a precise evaluation of vascular complications, the anatomy of the biliary tree, and the extension of inflammation to surrounding structures (i.e., colitis). Therefore, based also on our experience, in patients with atypical presentation, or in cases with high suspicion for a complicated form, a MDCT abdomen scan is performed. In this review, the principal findings are listed and described to create a CT classification of acute complications based on anatomical and topographic criteria.

Endoscopic-catheter-directed infusion of diluted (-)-noradrenaline for atypical hemobilia caused by liver abscess: A case report

BACKGROUND

Hemobilia occurs when there is a fistula between hepatic blood vessels and biliary radicles, and represents only a minority of upper gastrointestinal hemorrhages. Causes of hemobilia are varied, but liver abscess rarely causes hemobilia and only a few cases have been reported. Here, we present a case of atypical hemobilia caused by liver abscess that was successfully managed by endoscopic hepatobiliary intervention through endoscopic retrograde cholangiopancreatography (ERCP).

CASE SUMMARY

A 54-year-old man presented to our emergency department with a history of right upper quadrant abdominal colic and repeated fever for 6 d. Abdominal sonography and enhanced computed tomography revealed that there was an abscess in the right anterior lobe of the liver. During hospitalization, the patient developed upper gastrointestinal bleeding. Upper gastrointestinal endoscopy revealed a duodenal ulcer bleeding that was treated with three metal clamps. However, the hemodynamics was still unstable. Hence, upper gastrointestinal endoscopy was performed again and fresh blood was seen flowing from the ampulla of Vater. Selective angiography did not show any abnormality. An endoscopic nasobiliary drainage (ENBD) tube was inserted into the right anterior bile duct through ERCP, and subsequently cold saline containing (-)-noradrenaline was infused into the bile duct lumen through the ENBD tube with no episode of further bleeding.

CONCLUSION

Hemobilia should be considered in the development of liver abscess, and endoscopy is essential for diagnosis and management of some cases.

Transcatheter arterial embolization for massive hemobilia with N-butyl cyanoacrylate (NBCA) Glubran 2

BACKGROUND

Massive hemobilia is a life-threatening condition and therapeutic challenge. Few studies have demonstrated the use of N-butyl cyanoacrylate (NBCA) for massive hemobilia.

PURPOSE

To investigate the efficacy and safety of transcatheter arterial embolization (TAE) using NBCA Glubran 2 for massive hemobilia.

MATERIAL AND METHODS

Between January 2012 and December 2019, the data of 26 patients (mean age 63.4 ± 12.6 years) with massive hemobilia were retrospectively evaluated for TAE using NBCA. The patients' baseline characteristics, severities of hemobilia, and imaging findings were collected. Emergent TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil. Technical success, clinical success, procedure-related complications, and follow-up outcomes were assessed.

RESULTS

Pre-procedure arteriography demonstrated injuries to the right hepatic artery (n = 24) and cystic artery (n = 2). Initial coil embolization distal to the lesions was required in 5 (19.2%) patients to control high blood flow and prevent end-organ damage. After a mean treatment time of 11.2 ± 5.3 min, technical success was achieved in 100% of the patients without non-target embolization and catheter adhesion. Clinical success was achieved in 25 (96.2%) patients. Major complications were noted in 1 (3.8%) patient with gallbladder necrosis. During a median follow-up time of 16.5 months (range 3-24 months), two patients died due to carcinomas, whereas none of the patients experienced recurrent hemobilia, embolic material migration, or post-embolization complications.

CONCLUSION

NBCA embolization for massive hemobilia is associated with rapid and effective hemostasis, as well as few major complications. This treatment modality may be a promising alternative to coil embolization.

Clinical features of hemobilia: Report of six cases and a literature review

BACKGROUND

Hemobilia is a rare cause of upper gastrointestinal bleeding. Diagnosis and treatment of hemobilia can be difficult and challenging.

AIM

To explore the causes of and treatment methods for hemobilia to improve its diagnosis and treatment.

METHODS

The clinical data, causes of bleeding, and treatment methods for six patients with hemobilia diagnosed at our hospital from 2014 to 2018 were analyzed, and the relevant literature was reviewed to summarize the diagnosis and treatment processes of hemobilia.

RESULTS

Of the six patients with hemobilia (including two females; mean age, 54.2 years), two had tumor lesions, one had gallbladder stones, one had gallbladder pseudoaneurysm, one underwent liver transplantation previously, and one had biliary tract infection; two were treated by surgery, one underwent endoscopic treatment, one underwent vascular intervention, and two were pharmacologically treated; five were cured, and one died from hemorrhagic shock.

CONCLUSION

Diagnosis and treatment of hemobilia are difficult and challenging. Improving the understanding of hemobilia, timely and meticulous examination, and reasonable selection of treatment methods are the keys to improving the diagnosis and treatment of hemobilia.

Noninvasive Imaging Prior to Biliary Interventions

Noninvasive imaging is a crucial and initial step in the diagnostic algorithm of patients with suspected biliary pathology and directs the subsequent diagnostic and therapeutic workup, including the endoluminal and percutaneous biliary interventions. This article reviews the current noninvasive imaging methods for the evaluation of biliary system and further discusses their roles in the diagnostic workup of different biliary disease.

Massive hemobilia caused by rupture of gastroduodenal artery pseudoaneurysm, a delayed complication of laparoscopic cholecystectomy: a case report

BACKGROUND

Hemobilia is a rare cause of upper gastrointestinal bleeding that originates from the biliary tract. It is infrequently considered in diagnosis, especially in the absence of abdominal trauma or history of hepatopancreatobiliary procedure, such as cholecystectomy, which can cause arterial pseudoaneurysm. Prompt diagnosis is crucial because its management strategy is distinct from other types of upper gastrointestinal bleeding. Here, we present a case of massive hemobilia caused by the rupture of a gastroduodenal artery pseudoaneurysm in a patient with a history of laparoscopic cholecystectomy 3 years prior to presentation.

CASE PRESENTATION

A 44-year-old Indonesian female presented to the emergency department with complaint of hematemesis and melena accompanied by abdominal pain and icterus. History of an abdominal trauma was denied. However, she reported having undergone a laparoscopic cholecystectomy 3 years prior to presentation. On physical examination, we found anemic conjunctiva and icteric sclera. Nonvariceal bleeding was suspected, but esophagogastroduodenoscopy showed a blood clot at the ampulla of Vater. Angiography showed contrast extravasation from a gastroduodenal artery pseudoaneurysm. The patient underwent pseudoaneurysm ligation and excision surgery to stop the bleeding. After surgery, the patient's vital signs were stable, and there was no sign of rebleeding.

CONCLUSION

Gastroduodenal artery pseudoaneurysm is a rare complication of laparoscopic cholecystectomy. The prolonged time interval, as compared with other postcholecystectomy hemobilia cases, resulted in hemobilia not being considered as an etiology of the gastrointestinal bleeding at presentation. Hemobilia should be considered as a possible etiology of gastrointestinal bleeding in patients with history of cholecystectomy, regardless of the time interval between the invasive procedure and onset of bleeding.

Challenges in Diagnosis and Management of Hemobilia

Hemobilia, or hemorrhage within the biliary system, is an uncommon form of upper gastrointestinal (GI) bleeding that presents unique diagnostic and therapeutic challenges. Most cases are the result of iatrogenic trauma, although accidental trauma and a variety of inflammatory, infectious, and neoplastic processes have also been implicated. Timely diagnosis can often be difficult, as the classic triad of upper GI hemorrhage, biliary colic, and jaundice is present in a minority of cases, and there may be considerable delay in the onset of bleeding after the initial injury. Therefore, the radiologist must maintain a high index of suspicion for this condition and be attuned to its imaging characteristics across a variety of modalities. CT is the first-line diagnostic modality in evaluation of hemobilia, while catheter angiography and endoscopy play vital and complementary roles in both diagnosis and treatment. The authors review the clinical manifestations and multimodality imaging features of hemobilia, describe the wide variety of underlying causes, and highlight key management considerations.^©RSNA, 2021.

Delayed and Chronic Sequelae of Trauma and the Role of the Interventional Radiologist

In addition to acute injury requiring interventional radiologic treatments, patients with traumatic injuries can develop delayed or chronic complications. These injuries can involve nearly all solid organs in the abdomen. Coupled with significant improvements in visualizing these injuries with advanced imaging techniques such as minimally invasive procedures, nonoperative management of both acute traumatic injuries and their longer term sequelae has become the norm. This article reviews frequently seen complications of traumatic injury and their management by interventional radiologists.

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhage

Acute hemorrhagic cholecystitis is a rare, life-threatening condition that can be further complicated by perforation of the gallbladder. We describe a patient with clinical and radiologic findings of acute cholecystitis with a gallbladder rupture and massive intra-abdominal bleeding. Our patient is a 67-year-old male who presented with an ischemic stroke and was treated with early tissue plasminogen activator. His hospital course was complicated by a fall requiring posterior spinal fusion surgery. He recovered well, but several days later developed subxiphoid and right upper quadrant pain and an episode of hemobilia and melena. A computed tomography scan revealed an inflamed, distended gallbladder with indistinct margins and a large hematoma in the gallbladder fossa extending to the right paracolic gutter. The patient also developed hemodynamic instability concerning for hemorrhagic shock. He underwent an emergent laparoscopic converted to open subtotal fenestrating cholecystectomy with abdominal washout for management of his acute hemorrhagic cholecystitis with massive intra-abdominal hemorrhage. Prompt recognition of this lethal condition in high-risk patients is crucial for optimizing patient care.

The development of a predictive risk model on post-ablation hemobilia: a multicenter matched case-control study

Objective:

This study aimed to develop a predictive risk model for post-ablation hemobilia.

Methods:

This was a retrospective, multicenter, matched case–control study. The case group comprised patients with hepatocellular carcinoma who developed post-ablation hemobilia (n = 21); the control group (n = 63) comprised patients with hepatocellular carcinoma but no post-ablation hemobilia; for each case, we included three controls matched for age, sex, platelet count, year of ablation therapy, and center. Univariate and multivariate regression analyses were performed to identify the risk factors for hemobilia. A risk score model was developed based on adjusted odds ratios (ORs).

Results:

The independent risk factors for occurrence of post-ablation hemobilia were maximum tumor diameter >47 mm [OR = 5.983, 95% CI (1.134–31.551)] and minimum distance from the applicator to the portal trunk ≤8 mm [OR = 4.821, 95% CI (1.225–18.975)]. The risk model was developed using the adjusted ORs; thus a score of 6 was assigned to the former and a score of 5 for the latter. The area under the curve of this risk model was 0.76. Significant hemodynamic instability and inaccurate embolization might increase the risk of recurrence of hemobilia.

Conclusion:

Tumor size >47 mm and distance of the applicator from the portal trunk ≤8 mm are independent risk factors for hemobilia. A predictive risk model for post-ablation hemobilia was developed using these risk factors.

Advances in knowledge:

This is the first study that developed a risk score model of post-ablation hemobilia. Risk factors of the recurrence of post-ablation hemobilia were also been identified.

Hemobilia after bile duct resection: perforation of pseudoaneurysm into intra-pancreatic remnant bile duct: a case report

BACKGROUND

Hemobilia occurs mainly due to iatrogenic factors such as impairment of the right hepatic or cystic artery, and/or common bile duct in hepatobiliary-pancreatic surgery. However, little or no cases with hemobilia from the intra-pancreatic remnant bile duct after bile duct resection (BDR) has been reported. Here, we report a case of massive hemobilia due to the perforation of psuedoaneurysm of the gastroduodenal artery (GDA) to the intra-pancreatic remnant bile duct after hepatectomy with BDR.

CASE PRESENTATION

A 68-year-old male underwent extended right hepatectomy with BDR for gallbladder carcinoma. He presented with upper gastrointestinal bleeding 2 months after the initial surgery. Upper endoscopy identified a blood clot from the ampulla of Vater and simultaneous endoscopic balloon tamponade contributed to temporary hemostasis. Abdominal CT and angiography revealed a perforation of the psuedoaneurysm of the GDA to the intra-pancreatic remnant bile duct resulting in massive hemobilia. Subsequent selective embolization of the pseudoaneurysm with micro-coils could achieve complete hemostasis. He survived without any recurrence of cancer and bleeding.

CONCLUSION

Hemobilia could occur in a patient with BDR due to perforation of the pseudoaneurysm derived from the GDA to the intra-pancreatic remnant bile duct. Endoscopic balloon tamponade was useful for a temporal hemostasis and a subsequent radiologic interventional approach.