Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent

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.

Portal-Vein Compression Caused by Double-Pigtail Plastic Biliary Stent

Introduction

Reports of pseudoaneurysms associated with biliary self-expandable metallic stent (SEMS) placement have been increasing. Recently, cases of hepatic pseudoaneurysm rupture caused by double pigtail plastic stents (DPS) have also been reported. The symptoms of pseudoaneurysms are often non-specific, and many cases are diagnosed only after rupture. Therefore, early detection and appropriate treatment are required.

Case Presentation

A 45-year-old woman presented with obstructive jaundice caused by pancreatic head cancer, with imaging revealing common bile duct stenosis and intrahepatic bile duct dilation. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to place a DPS in the left hepatic duct, relieving jaundice. However, follow-up contrast-enhanced computed tomography (CE-CT) revealed differences in arterial-phase blood flow between the liver lobes without reduction in portal vein blood flow. Therefore, the compression and stenosis of the left branch of the portal vein caused by the DPS were clearly identified using three-dimensional computed tomography (3D-CT). The DPS was replaced with a straight-type stent, preventing further complications. The patient subsequently underwent successful pancreaticoduodenectomy without any surgical complications.

Conclusion

This is a case of portal vein compression caused by double-pigtail plastic biliary stent. By promptly recognizing the differences in arterial-phase blood flow between the liver lobes and replacing the DPS with a straight-type plastic stent, complications, such as portal vein pseudoaneurysm formation, rupture, embolism, or thrombosis, were successfully avoided.

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.

Metal Stents for the Management of Massive Hemobilia in Patients with Hilum-Involving Cholangiocarcinoma Receiving Multi-Regimen Chemotherapy

Recent clinical outcomes of multi-regimen chemotherapy in patients with cholangiocarcinoma (CCC) have shown benefits in terms of overall survival. However, repeated endoscopic biliary drainage (EBD) and serious adverse events negatively affect prolongation of the survival period. The aim of this study was to investigate the prevalence of massive hemobilia and the outcomes of its management with fully covered self-expandable metal stents (FC-SEMSs) in patients with hilum-involving CCC receiving multi-regimen chemotherapy. The methods and effects of FC-SEMS placement were retrospectively investigated following the occurrence of massive hemobilia during EBD. A total of 356 patients with CCC received multi-regimen chemotherapy. Among them, 181 patients had hilar invasion, and seven patients (3.9%) developed massive hemobilia during repeated EBD using removable stents. In all cases, the tumor encased the right hepatic artery. In six patients (85.7%), hemostasis was immediately and completely achieved by inserting one or two FC-SEMSs proximal to the hilar invasion area. Therefore, if the tumor encases the right hepatic artery, massive hemobilia is likely to occur during multi-regimen chemotherapy. Thus, prompt placement of a FC-SEMS would be an effective treatment option for massive hemobilia in patients with hilum-involving CCC.

Ruptured pseudoaneurysm in a biliary metallic stent in a patient with pancreatic cancer: a case report

We report a case of an 87 year-old woman who was admitted with jaundice, but had no pain or fever. Contrast-enhanced computed tomography revealed a tumor in the head of the pancreas, which caused distal malignant biliary obstruction. Initial transpupillary drainage by endoscopic retrograde cholangiopancreatography (ERCP) was difficult due to severe biliary stricture caused by the tumor, but cannulation of the pancreatic duct was successful. Pancreatic ductal adenocarcinoma was revealed through cytologic examination of pancreatic juice and the patient underwent percutaneous transhepatic biliary drainage (PTBD). 16 days after the jaundice was resolved, an uncovered Zilver® metallic stent was successfully deployed using a guidewire from the PTBD route, and the patient was discharged with palliative care due to advanced age. However, 54 days after discharge, the patient presented with black vomiting and recurrent jaundice. ERCP revealed an obstructed stent with black debris, and further evaluation revealed a ruptured pseudoaneurysm that branched off the gastroduodenal artery within the metallic biliary stent. Angiography revealed that embolization was successful. The patient recovered and was discharged without further episodes.

Ruptured cystic artery pseudoaneurysm after self-expandable metal stent placement for malignant biliary obstruction

We report a case of ruptured cystic artery pseudoaneurysm after self-expandable metal stent placement for malignant biliary obstruction. A 78-year-old woman on palliative care after chemotherapy for unresectable pancreatic head cancer presented with obstructive jaundice. Imaging revealed a dilated common bile duct and an enlarged gallbladder with cystic wall thickening. Endoscopic retrograde cholangiopancreatography was performed and a fully-covered self-expandable metal stent was placed in the bile duct, leading to resolution of jaundice. She presented with hematochezia 7 days later. Contrast-enhanced computed tomography revealed a cystic artery pseudoaneurysm with extravasation of contrast into a blood-filled gallbladder. Hemostasis was achieved after emergent transcatheter arterial embolization. Rupture of cystic artery pseudoaneurysm should be raised as a differential diagnosis for hemobilia after self-expandable metal stent placement, particularly in cases accompanied by inflamed gallbladders.

Late-onset hemobilia due to pseudoaneurysm rupture after endoscopic ultrasound-guided hepaticogastrostomy

We report the case of a 65-year-old man who experienced hemobilia due to rupture of a pseudoaneurysm of the left hepatic artery after endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS). The patient was diagnosed with pancreatic cancer and underwent endoscopic retrograde cholangiopancreatography for obstructive jaundice. Biliary drainage was converted to EUS-HGS due to tumor invasion in the superior duodenal angle. A partially covered metal stent was placed in the B3 intrahepatic bile duct. The procedure was completed without early complications, but 50 days later, the patient developed fever, elevated hepatobiliary enzymes, and shock. Contrast-enhanced computed tomography (CT) showed that the hepatic end of the HGS stent had moved slightly toward the stomach compared to the previous CT. A 6-mm pseudoaneurysm was also observed near the A3 and A4 branches of the left hepatic artery, coinciding with the hepatic end of the EUS-HGS stent. Hemostasis was achieved with coil embolization. Biliary hemorrhage due to rupture of a pseudoaneurysm should be considered in the differential diagnosis of biliary obstruction accompanied by bleeding after EUS-HGS.

Rapid identification of source of delayed hemobilia following endoscopic metallic stenting for malignant biliary obstruction

Delayed hemobilia, a rare but potentially fatal complication of endoscopic metallic stenting for malignant biliary obstruction, requires prompt identification of the source of bleeding and subsequent embolization. However, hemobilia is characteristically intermittent, and computed tomography (CT) often fails to show pseudoaneurysms or extravasations. In particular, because the posterior superior pancreaticoduodenal artery (PSPDA) runs alongside the common bile duct for its whole length, it is readily obscured by metallic artifacts in that duct, such as stents, making identification of the source of bleeding by CT difficult. We have encountered three patients with delayed hemobilia from the PSPDA following endoscopic biliary stenting for malignant biliary obstruction in whom no extravasation or pseudoaneurysms were detected by contrast-enhanced CT during bleeding. However, when we identified that the PSPDA had a smaller diameter than in previous CTs in all three cases, we suspected that the PSPDA was the source of the bleeding. No extravasation or pseudoaneurysms were detected with celiac arteriography or superior mesenteric arteriography; however, extravasation and pseudoaneurysms were detected by direct PSPDA angiography. Hemostasis was achieved through embolization. Detecting a large decrease in the diameter of the PSPDA on contrast-enhanced CT during biliary bleeding may help to identify the source of that 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.

Transcatheter arterial embolization for gastrointestinal bleeding related to pancreatic adenocarcinoma: clinical efficacy and predictors of clinical outcome

PURPOSE

To evaluate the clinical efficacy of transcatheter arterial embolization (TAE) for managing pancreatic adenocarcinoma-related gastrointestinal (GI) bleeding, and to determine the factors associated with clinical outcomes.

METHOD

From 2001-2017, this retrospective study included 58 patients who underwent TAE for pancreatic adenocarcinoma-related GI bleeding. The technical and clinical success of TAE, clinical factors including patient characteristics and embolization details, complications, and the 30-day mortality were evaluated. Univariate analyses were performed to determine the factors related to the clinical outcomes.

RESULTS

On angiography, bleeding foci were detected in 47 patients (81%), while the other 11 patients showed tumor staining. Technical success rate was 98%, and first session and overall clinical success rates were 79% and 88%, respectively. N-butyl cyanoacrylate (NBCA) was the most commonly used embolic agent (53%). Stent-related bleeding was shown in 22 patients with characteristic angiogram such as arterial cut-off (13/22) and arteriobiliary fistula (5/22), with comparable clinical success rate (82%). Bleeding from the superior mesenteric artery (n = 3) at the first session of angiography and complications (n = 2), such as ischemic hepatitis and small bowel infarction, were all associated with a 30-day mortality. The overall 30-day mortality rate was 22%. Univariate analysis showed that massive transfusion and TNM stage 4 were related to clinical failure (P = 0.035 and 0.038, respectively).

CONCLUSIONS

TAE was effective and safe for pancreatic adenocarcinoma-related GI bleeding. Stent-related bleeding was not uncommon, and associated with vascular abnormality amenable to TAE. Massive transfusion and TNM stage 4 were related to clinical failure.

Embolization for delayed arterial bleeding after percutaneous self-expandable metallic stent placement in patients with malignant biliary obstruction

OBJECTIVES

To retrospectively evaluate the safety and efficacy of transcatheter arterial embolization (TAE) for delayed arterial bleeding secondary to percutaneous self-expandable metallic stent (SEMS) placement in patients with malignant biliary obstruction (MBO).

METHODS

From January 1997 to September 2017, 1858 patients underwent percutaneous SEMS placement for MBO at a single tertiary referral center. Among them, 19 patients (mean age, 70.2 [range, 52-82] years; 13 men) presented with delayed SEMS-associated arterial bleeding and underwent TAE.

RESULTS

The incidence of delayed arterial bleeding was 1.0% (19/1858) after SEMS placement, with a median time interval of 225 days (range, 22-2296). Digital subtraction angiography (DSA) showed pseudoaneurysm alone close to the stent mesh (n = 10), pseudoaneurysm close to the stent mesh with contrast extravasation to the duodenum (n = 3), pseudoaneurysm close to the stent mesh with arteriobiliary fistula (n = 1), in-stent pseudoaneurysm alone (n = 4) and in-stent pseudoaneurysm with arteriobiliary fistula (n = 1). Bleeding was stopped after the embolization in all patients. Overall clinical success rate was 94.7% (18/19). One patient with recurrent bleeding was successfully treated with a second embolization. Overall 30-day mortality rate was 26.3% (5/19). A major procedure-related complication was acute hepatic failure in one hilar bile duct cancer patient (5.3%), which was associated with an obliterated portal vein.

CONCLUSION

TAE is safe and effective for the treatment of delayed arterial bleeding after percutaneous SEMS placement for MBO.

ADVANCES IN KNOWLEDGE

This study demonstrated TAE is safe and effective for arterial bleeding after SEMS placement after MBO through the largest case series so far.

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.

Haemobilia due to hepatic artery pseudoaneurysm

An 83-year-old woman with a history of hepaticoduodenostomy 20 years ago was admitted with upper gastrointestinal bleeding. Emergency upper gastrointestinal endoscopy revealed multiple blood clots over the stomach and first and second parts of the duodenum. The cannulation of the biliary tree with a flexible end-viewing endoscope exposed the presence of blood clot inside biliary lumen and a semipedunculated polyp which, at first, appeared to be the cause of haemorrhage. A few days after polypectomy, patient was discharged home, however, was admitted again with massive bleeding and selective angiography demonstrated a pseudoaneurysm of left hepatic artery. Angioembolisation was performed and haemorrhage was stopped afterwards.

Delayed Severe Hemobilia after Endoscopic Biliary Plastic Stent Insertion

Hemobilia is a rare gastrointestinal bleeding, usually caused by injury to the bile duct. Hemobilia after endoscopic retrograde cholangiopancreatography (ERCP) is generally self-limiting and patients will spontaneously recover, but some severe and fatal hemorrhages have been reported. ERCP-related bowel or bile duct perforation should be managed promptly, according to the type of injury and the status of the patient. We recently experienced a case of late-onset severe hemobilia in which the patient recovered after endoscopic biliary stent insertion. The problem was attributable to ERCP-related bile duct perforation during stone removal, approximately 5 weeks prior to the hemorrhagic episode. The removal of the stent was performed 10 days before the onset of hemobilia. The bleeding was successfully treated by two sessions of transarterial coil embolization.

Delayed, life-threatening hemorrhage after self-expandable metallic biliary stent placement: clinical manifestations and endovascular treatment

BACKGROUND

Life-threatening, delayed hemorrhage after self-expandable metallic stent (SEMS) insertion for malignant biliary obstruction is very rare. Clinical manifestations, radiologic characteristics, treatment, and prognosis of this complication are not well-known.

PURPOSE

To present the clinical manifestations, radiologic findings, and endovascular treatment of life-threatening, delayed hemorrhage secondary to SEMS placement.

MATERIAL AND METHODS

A total of six patients (five men and one woman; mean age, 65.5 years) with life-threatening, delayed arterial bleeding after SEMS placement for malignant bile duct obstruction were recruited between 2000 and 2011 from three different hospitals in Korea. The original SEMS placement in all patients utilized either percutaneous (n = 3) or endoscopic approaches (n = 3). We retrospectively reviewed the clinical presentations, computed tomography (CT) and angiographic findings, endovascular treatments, and prognoses of these patients.

RESULTS

All patients presented with life-threatening gastrointestinal bleeding such as melena (n = 4), hematochezia (n = 1), and hematemesis (n = 1). Mean time period between biliary metallic stent insertion and presentation with bleeding was 75 days (range, 15-152 days). All stents were encased by primary or metastatic cancer along with nearby arteries on CT images. Digital subtraction angiogram (DSA) revealed pseudoaneurysm close to the stent (n = 2), in-stent pseudoaneurysm (n = 2), arteriobiliary fistula (n = 1), or pseudoaneurysm with arteriobiliary fistula (n = 1). The origins of hemorrhage were the gastroduodenal artery (n = 3), the aberrant right posterior hepatic artery from the gastroduodenal artery (n = 2), and the right hepatic artery (n = 1). Hemorrhages were successfully controlled after intra-arterial coil embolization in five patients followed by placement of a stent graft and direct puncture N-butyl-2-cyanoacrylate (NBCA) embolization in one patient.

CONCLUSION

Life-threatening, delayed hemorrhage within a metallic biliary stent may occur if a stent is placed across the bulky bile duct tumor or tumor encases the stent. Bleeding can be successfully treated with endovascular treatment. However, the overall prognosis was poor.

Intrahepatic artery pseudoaneurysm associated with a metallic biliary stent after living donor liver transplantation: report of a case

An intrahepatic artery pseudoaneurysm (IHAA) is a very rare but potentially lethal complication occurring after liver transplantation. This report presents a case of an IHAA associated with a metallic biliary stent after liver transplantation. A 40-year-old male underwent living donor liver transplantation (LDLT) using a left lobe graft. The bile duct reconstruction was performed with Roux-en-Y hepaticojejunostomy. He developed obstructive jaundice 5 years after LDLT, and had biliary stricture of the anastomosis area, therefore, the two metallic biliary stents were finally positioned at the stricture of the biliary tract. He suddenly developed hematemesis 8 years after LDLT, and computerized tomography scan showed an IHAA. Although seven interlocking detachable coils were placed at the neck of the aneurysm, hematemesis recurred 3 days after the initial embolization. Therefore, retransplantation was successfully performed 25 days after the embolization of IHAA using a right lobe graft from his son. In conclusion, metal stent insertion can lead to the fatal complication of HAA. The placement of a metallic stent could have been avoided in this case. Percutaneous metallic stent insertion for biliary stenosis after liver transplantation should therefore only be performed in carefully selected patients.

Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer

We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.

Hemobilia

Hemobilia is an uncommon medical problem that presents in a varied fashion and is increasingly of iatrogenic origin. The diagnosis of hemobilia needs to be considered in patients presenting with upper gastrointestinal bleeding, particularly if they are jaundiced with abdominal pain in the setting of recent or previous percutaneous liver intervention or abdominal trauma. Multislice computed tomographic angiography is increasingly being used in the investigation, but transcatheter arterial embolization remains the cornerstone of managing those patients requiring intervention. The majority of patients with hemobilia will be managed supportively or with radiologic intervention; most do not require surgical intervention.

Life-threatening hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy: report of a case

BACKGROUND

Hemobilia is a rare but lethal biliary tract complication. There are several causes of hemobilia which might be classified as traumatic or nontraumatic. Hemobilia caused by pseudoaneurysm might result from hepatobiliary surgery or percutaneous interventional hepatobiliary procedures. However, to our knowledge, there are no previous reports pertaining to hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy.

CASE PRESENTATION

A 65-year-old male was admitted to our hospital because of acute calculous cholecystitis and cholangitis. He underwent cholecystectomy, choledocholithotomy via a right upper quadrant laparotomy and a temporary T-tube choledochostomy was created. However, on the 19th day after operation, he suffered from sudden onset of hematemesis and massive fresh blood drainage from the T-tube choledochostomy. Imaging studies confirmed the diagnosis of pseudoaneurysm associated hemobilia. The probable association of T-tube choledochostomy with pseudoaneurysm and hemobilia is also demonstrated. He underwent emergent selective microcoils emobolization to occlude the feeding artery of the pseudoaneurysm.

CONCLUSIONS

Pseudoaneurysm associated hemobilia may occur after T-tube choledochostomy. This case also highlights the importance that hemobilia should be highly suspected in a patient presenting with jaundice, right upper quadrant abdominal pain and upper gastrointestinal bleeding after liver or biliary surgery.

A severe case of hemobilia and biliary fistula following an open urgent cholecystectomy

Background

Cholecystectomy has been the treatment of choice for symptomatic gallstones, but remains the greatest source of post-operative biliary injuries. Laparoscopic approach has been recently preferred because of short hospitalisation and low morbidity but has an higher incidence of biliary leakages and bile duct injuries than open one due to a technical error or misinterpretation of the anatomy. Even open cholecystectomy presents a small number of complications especially if it was performed in urgency. Hemobilia is one of the most common cause of upper gastrointestinal bleeding from the biliary ducts into the gastrointestinal tract due to trauma, advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage.

Methods

We report here a case of massive hemobilia in a 60-year-old man who underwent an urgent open cholecystectomy and a subsequent placement of a transhepatic biliary drainage.

Conclusion

The management of these complications enclose endoscopic, percutaneous and surgical therapies. After a diagnosis of biliary fistula, it's most important to assess the adequacy of bile drainage to determine a controlled fistula and to avoid bile collection and peritonitis. Transarterial embolization is the first line of intervention to stop hemobilia while surgical intervention should be considered if embolization fails or is contraindicated.

Complications and diagnostic difficulties arising from biliary self-expanding metal stent insertion before definitive histological diagnosis

BACKGROUND

Self-expanding metal bile duct stents provide good palliation for inoperable malignant disease. However, problems may arise if metal stents are inserted before definitive histological diagnosis. The aim of this study was to evaluate the outcome of such patients.

METHODS

A retrospective case note review was conducted of patients referred to a tertiary pancreaticobiliary center between 1992 and 2004 in whom a metal bile duct stent was inserted for presumed unresectable malignant disease before definitive histological diagnosis.

RESULTS

There were 21 patients identified. Final diagnoses were: group 1, benign disease (n = 3); group 2, resectable malignancy (n = 2); group 3, unresectable malignancy (n = 12); and group 4, diagnosis remains uncertain (n = 4). During a follow-up of 22, 38 and 111 months, the patients in group 1 had one, eight and five episodes of stent occlusion. In group 2, both patients underwent pancreaticoduodenectomy for ampullary carcinoma, 2 and 6 months after presentation. In group 3, the median time to a confirmed malignant diagnosis was 2 months (range 1-27 months). In group 4, a median of two biopsies (range 1-4) were negative for malignancy, during a median follow up of 13 months (range 3-46). Overall in eight patients, the metal stents caused artifacts on computed tomography and/or were associated with tissue in-growth making the differentiation between benign and malignant disease difficult.

CONCLUSION

These cases indicate that metal bile duct stent insertion before definitive histological diagnosis can be problematic. A proportion of cases will have benign strictures and in others the confirmation of malignancy may be made more difficult.

Hepatic artery pseudoaneurysm associated with plastic biliary stent

The increased use of interventional procedures and laparoscopic cholecystectomy in the management of hepatobiliary disorders is associated with an increased incidence of hemobilia and hepatic artery aneurysm. Here we report a case of hepatic artery pseudoaneurysm associated with a plastic biliary stent. Multiple factors were involved in the formation of the hepatic artery aneurysm (HAA) and it was successfully treated by embolization.

Hemobilia caused by cytomegalovirus cholangiopathy

A 57-yr-old male on long-term steroid therapy presented with hematemesis, fever, and a retroperitoneal fluid collection. Hemobilia was diagnosed, but the cause was not identified by ERCP, computed tomography, or angiography. Peroral cholangioscopy revealed multiple biliary ulcers. Cholangioscopic biopsies diagnosed cytomegalovirus (CMV) infection. Intravenous ganciclovir therapy was initiated, and was associated with cessation of bleeding. Biliary CMV disease is rare in HIV-negative persons, but should be considered in a patient with unexplained hemobilia. Cholangioscopy may be useful for diagnosis.