Late-onset severe biliary bleeding after endoscopic pigtail plastic stent insertion

Identification of risk factors associated with post-ERCP pancreatitis in patients with easy cannulation: a prospective multicenter observational study (with videos)

BACKGROUND AND AIMS

Difficult biliary cannulation is an independent risk factor for post-ERCP pancreatitis (PEP); however, there is a noticeable lack of studies focusing on the incidence and risk factors of PEP among patients undergoing easy cannulation. Therefore, we systematically investigated the risk factors for PEP in patients who underwent easy cannulation.

METHODS

We prospectively enrolled patients with naive major papillae who underwent diagnostic or therapeutic ERCP between June 2018 and June 2023. The primary endpoint was to determine the incidence of PEP in patients with easy cannulation; secondary endpoints were identifying PEP risk factors and evaluating procedure-related adverse events (AEs).

RESULTS

Overall, 1930 patients were included, with 1061 (54.9%) undergoing easy cannulation. Within this cohort, PEP incidence was 3.0%, whereas 2.9% experienced procedure-related AEs, excluding PEP. A history of acute pancreatitis (odds ratio [OR], 6.75; 95% confidence interval [CI], 1.83-20.14; P = .001) and acute cholangitis on admission (OR, 2.25; 95% CI, 1.07-5.08; P = .039) were identified as independent risk factors for PEP in patients with easy cannulation. Endoscopic sphincterotomy and biliary stent placement were independent factors for procedure-related AEs.

CONCLUSIONS

Our findings underscore the importance of assessing patient- and procedure-related factors to mitigate the risk of PEP in patients undergoing easy cannulation. Despite the low incidence of PEP, the potential for the occurrence of severe cases emphasizes the need for cautious intervention, particularly in patients with a history of acute pancreatitis and acute cholangitis on admission. (Clinical trial registration number: KCT0005950.).

Pseudoaneurysms Post-biliary Stenting: A Comprehensive Literature Review

PURPOSE

Pseudoaneurysms (PSA) following endoscopic biliary stenting are a rare, potentially life-threatening adverse event. Incidence, diagnostic approach, treatment, and prevention of PSA remain unknown. In this comprehensive literature review, we aimed to evaluate the association of developing PSA following biliary stent placement.

METHODS

We conducted a comprehensive search of databases for studies that reported development of PSA after placement of a biliary stent. Full text review and data extraction were performed according to the PRISMA guidelines.

RESULTS

From 386 initial studies, 32 (n = 36 patients) met inclusion criteria. Thirty-one patients had stents placed in the common bile duct, four in the right or left hepatic ducts, and one in the cystic duct. The most common indication for stent placement was biliary obstruction from pancreatic adenocarcinoma with 69.4% of patients having primary pancreaticobiliary malignancy or metastases. 52.0% had received prior chemotherapy with or without localized radiation. Metal stents were used in 60.5% of cases and plastic stents in 37.2%. Average time to PSA presentation was 114 days, with gastrointestinal bleeding as the most common sign/symptom (75%). PSAs were most often located in the hepatic artery (55.6%), diagnosed by diagnostic angiography (55.6%), and treated with embolization (86.1%). No immediate deaths were reported and 83.3% of patients fully recovered.

CONCLUSION

The majority of PSAs presented with gastrointestinal bleeding and developed in patients who had metal stents placed for pancreaticobiliary malignancy. Prior history of previous chemotherapy/radiation or biliary procedures was common in this population. Angiography and embolization were used to diagnose and manage most cases.

Hemobilia due to hepatic artery pseudoaneurysm following biliary pigtail stent placement

Hemobilia is a potentially fatal condition if not diagnosed and treated early. One of the rare causes of hemobilia is hepatic artery pseudoaneurysm. Herein, we present a case of hemobilia caused by hepatic artery pseudoaneurysm rupture. A patient with a benign stricture in the distal common bile duct who had undergone multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures had a pigtail stent placed during the last ERCP. Ten days after the procedure, the patient presented to our emergency department with abdominal pain and was admitted with a diagnosis of acute pancreatitis. During follow-up, the patient underwent another ERCP due to suspected cholangitis, and severe hemobilia was observed following removal of the pigtail stent. Computed tomography (CT) angiography revealed a hepatic artery pseudoaneurysm, which was successfully treated with coil embolization. Patients with hemobilia may present with symptoms of upper gastrointestinal bleeding as well as conditions such as cholangitis and pancreatitis due to hepatic artery pseudoaneurysm rupture. Coil embolization is the first-line of interventional to stop bleeding. If this method is insufficient, surgical treatment may be considered.

Reduction of bleeding by cabozantinib in metastatic renal cell carcinoma with hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) is a rare genetic disorder characterized by refractory recurrent epistaxis and gastrointestinal bleeding. Recent studies have reported the hemostatic effects of tyrosine kinase inhibitors on HHT-related bleeding. A 67-year-old man with HHT underwent laparoscopic radical nephrectomy for right renal cell carcinoma discovered during an investigation of anemia. Five years after surgery, pancreatic metastasis with biliary dilatation was found on computed tomography. After a biliary stent was inserted, the patient was treated with cabozantinib plus nivolumab. His hemoglobin level significantly improved from 4.8 g/dL to a maximum of 14.7 g/dL, and transfusion frequency reduced from five to one per 5 months. Despite tumor reduction after 6 months of treatment, the patient developed acute cholangitis because of biliary hemorrhage, which ultimately resulted in hepatic failure and death. This case is the first to indicate the potential of the tyrosine kinase inhibitor cabozantinib to control bleeding and tumor progression in patients with metastatic renal cell carcinoma with HHT-related bleeding.

Hepatic artery pseudoaneurysm-the Mayo Clinic experience and literature review

Introduction

Hepatic artery pseudoaneurysm (HAP) is a rare and potentially life-threatening condition associated with high mortality. This study aims to review the etiology, clinical manifestations, management, and outcomes of patients diagnosed and treated for HAP at the Mayo Clinic.

Methodology

This study was a retrospective chart review of medical records for patients diagnosed and treated for hepatic artery pseudoaneurysm (HAP) at the Mayo Clinic (Florida, Minnesota, and Arizona) between September 1, 1998, and June 30, 2022. A total of 27 patients with HAP were identified, and their demographics, presenting symptoms, location of HAP, etiology, associated liver pathology, type of intervention, and outcomes were analyzed.

Results

The majority of patients with hepatic artery pseudoaneurysm (HAP) were male (63%), with a median age of 57 years (range: 25-87 years). HAP was predominantly intrahepatic (85.2%) and most commonly located on the right hepatic artery (RHA) (70.4%). In 89.9% of cases, the condition was attributable to hepatobiliary procedures or trauma, while only 10.1% occurred spontaneously. Presenting symptoms at the time of HAP diagnosis varied, including gastrointestinal (GI) bleeding (29.6%), abdominal pain (14.81%), non-GI bleeding (11.1%), traumatic bodily injury (11.1%), and other symptoms (14.81%). Asymptomatic or incidental findings of HAP were observed in 18% of cases. Malignancy was identified in 52% of patients, and 26% were liver transplant recipients. Statistical analysis revealed that factors such as prior knowledge of HAP (p = 0.381), HAP rupture (p = 0.382), anticoagulation therapy (p = 0.856), hemorrhagic shock (p = 0.25), liver cirrhosis (p = 0.143), gastrointestinal bleeding (p = 0.879), hepatobiliary abscess (p = 0.079), liver transplantation (p = 0.738), spontaneous HAP (p = 0.381), and malignancy (p = 0.163) were not significantly associated with increased mortality. In contrast, the need for transfusions (p = 0.021), tumor invasion (p = 0.023), portal vein thrombosis (PVT) (p = 0.02), and liver necrosis (p = 0.02) were significantly associated with higher mortality. The overall infection rate was 3%, while the mortality rate was 18.5%.

Discussion

Hepatic artery pseudoaneurysm (HAP) is a rare but serious condition often associated with hepatobiliary procedures, trauma, or liver transplants, though it can also occur spontaneously. While HAP is commonly detected incidentally, its diagnosis is frequently linked to complications such as rupture and gastrointestinal bleeding. However, our study suggests that these complications do not necessarily increase mortality. Key factors associated with higher mortality include the need for blood transfusions, tumor invasion, portal vein thrombosis, and liver necrosis at the time of diagnosis. The overall infection rate was low, but the mortality rate was 18.5%, highlighting the importance of early detection and management.

A rare incidence of a hepatic artery pseudoaneurysm following plastic biliary stent insertion

Hepatic artery pseudoaneurysms have been reported to occur in approximately 1% of cases after metal stenting for malignant biliary obstruction. In contrast, only a few cases have been reported as complications after plastic stenting for benign biliary disease. We report a 61-year-old man with cholangitis who presented with a rare complication of hemobilia after implantation of 7 Fr double pigtail plastic biliary stents. No bleeding was observed approximately one month after biliary stent tube removal. Contrast-enhanced CT scan revealed a circularly enhanced lesion (5 mm in diameter) in the arterial phase at the tip of the previously inserted plastic bile duct stent. Color Doppler ultrasonography enhanced the lesion and detected arterial blood flow inside. He was diagnosed with a hepatic artery pseudoaneurysm. However, he had no risk factors such as prolonged catheterization, severe cholangitis, liver abscess, or long-term steroid use. Superselective transarterial embolization using two metal microcoils was successfully completed without damage to the surrounding liver parenchyma. If hemobilia is suspected after insertion of a plastic bile duct stent, immediate monitoring using contrast-enhanced computed tomography or Doppler ultrasonography is recommended.

Delayed Hemobilia: A Rare Case of Biliary Bleeding One Year After Metallic Stent Placement

Hemobilia is a rare cause of upper GI bleed. This case report discusses hemobilia caused as a delayed complication of self-expanding metallic stent (SEMS) placement in a 65-year-old male. Our patient had a history of hepatitis C and an unresectable hepatocellular carcinoma, treated with chemotherapy and radiation therapy, which caused obstructive jaundice, which in turn led to the placement of SEMS. This case highlights the challenges in managing late-onset biliary bleeding, especially in patients with underlying malignancies. Detection of bleeding in a timely manner is crucial in devising the treatment plan. Angiographic occlusion is the first line of management to stop the bleed followed by definitive surgery or stent revision. Severe complications can occur in patients with poor general health. This case report addresses the importance of monitoring the patient and the need for collaborative efforts across specialties in managing complex cases. Despite the best efforts of the medical team, this case serves as a reminder of the complex and twisted nature of medical conditions, telling us the importance of developing suitable treatment strategies for each patient's needs and healthcare requirements.

Left hepatic artery pseudoaneurysm complicating endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND

Pseudoaneurysms of the hepatic artery or its branches have been reported following abdominal trauma, iatrogenic injury at the time of many operations such as percutaneous transhepatic biliary drainage and cholecystectomy. Hepatic artery pseudoaneurysms after endoscopic retrograde cholangiopancreatography (ERCP) are uncommon and potentially life threatening and should be identified and treated rapidly.

CASE SUMMARY

We report a case of intra-abdominal hemorrhage secondary to a left hepatic artery pseudoaneurysm resulting from guide wire injury at ERCP. The patient primary diagnosis was acute biliary pancreatitis with cholangitis, he underwent ERCP on the third day of admission. During ERCP, the left intrahepatic bile duct was cannulated three times. Over the sixth day, Contrast enhanced computed tomography scan demonstrated left hepatic lobe contusion and a pseudoaneurysm formation. The patient was successfully treated with the embolization of a small branch of left hepatic artery angiographically.

CONCLUSION

The common complications of ERCP are pancreatitis, bleeding and perforation. False aneurysms occur as a result of damage to the wall of an artery. As far as we know, it is rare complication has been reported following ERCP. We advise urgent referral for angiographic embolization in this situation to avoid aneurysm rupture.

Safety of biliary stent placement followed by definitive chemoradiotherapy in patients with pancreatic cancer with bile duct obstruction

Background

Although patients with malignant bile duct obstruction due to pancreatic cancer are often initially treated with biliary stent placement, concurrent chemoradiotherapy with stents poses a potential risk of increased toxicity. This retrospective study aimed to evaluate the safety of biliary stent placement followed by definitive concurrent chemoradiotherapy in patients with pancreatic cancer.

Methods

Patients with pancreatic cancer who underwent either a plastic stent or a self-expanding metallic stent placement for malignant bile duct obstruction before definitive concurrent chemoradiotherapy were retrospectively reviewed. Radiotherapy was delivered in 1.8 Gy per fraction to a total dose of 50.4 Gy. Gemcitabine, TS-1 plus Gemcitabine, or TS-1 was the concurrent chemotherapy/regimen. The primary endpoint was the rate of biliary stent-related toxicities, defined as biliary bleeding, duodenal perforation, or bile duct perforation.

Results

Thirty patients were included. Plastic stents were placed in 23 patients and self-expanding metallic stent in seven patients at the start of irradiation. The median follow-up time was 20 (range, 2-63) months, and 27 patients (90%) completed concurrent chemoradiotherapy. Biliary stent-related toxicity (grade 3 biliary bleeding) was confirmed in one patient (3%) with a plastic stent 9 months after concurrent chemoradiotherapy. The median duration of locoregional control, progression-free survival, and overall survival were 31.1, 7.3, and 10.5 months, respectively.

Conclusions

Stent placement followed by concurrent chemoradiotherapy was not associated with an apparent increase in toxicity and may be an appropriate treatment for patients with locally advanced pancreatic head cancer with bile duct obstruction.

Rupture of Pseudoaneurysm after Biliary Metallic Stent Placement

Rupture of a pseudoaneurysm (PA) has been reported as a rare but serious adverse event associated with endoscopic biliary stenting. We herein report 2 cases of severe biliary bleeding from a PA that developed 10-14 days after placement of a self-expandable metallic stent (SEMS) for biliary malignancy. The first patient was successfully embolized with endovascular coiling. However, the second patient had wide-spreading cholangiocarcinoma and, despite being treated once by full coiling, developed a second rupture of PA two months after starting systemic chemotherapy. Clinicians should be aware of the possibility of PA and carefully follow stented patients after endovascular treatment.

Massive hemobilia following plastic stent removal in common bile duct cancer associated with primary sclerosing cholangitis (with video)

Hemobilia is defined as bleeding into the biliary tract. Herein, we report a very rare case of massive hemobilia following plastic stent (PS) removal in common bile duct (CBD) cancer. A 72-year-old man with primary sclerosing cholangitis had undergone repeated insertion of a PS into the CBD. Biliary tract biopsy was performed based on suspicion of combined CBD cancer. Biopsy revealed poorly differentiated adenocarcinoma of the CBD. One month after the biliary tract biopsy, he was admitted for acute cholangitis, and endoscopic retrograde cholangiography was performed for the exchange of the PS. When one of the two biliary PSs was removed, spurting bleeding from the major papilla began abruptly. The massive bleeding caused the patient to be in a pre-shock state. A retrieval balloon catheter was compressed against the papilla for hemostasis. Although he was treated conservatively, the patient developed a bloody discharge. Upper gastrointestinal endoscopy revealed that the pulsatile bleeding beside the PSs started immediately after the removal of the coagula. Emergent contrast-enhanced computed tomography showed right hepatic artery aneurysm across the CBD. Therefore, transarterial embolization was performed. The patient's post-therapeutic course was uneventful. He received chemotherapy, but died about a half year after hemobilia occurred.