Clin Endosc.  2016 May;49(3):303-307. 10.5946/ce.2015.081.

Delayed Severe Hemobilia after Endoscopic Biliary Plastic Stent Insertion

• Lee SH
• Hong SG
• Lee KY
• Park PK
• Kim SD
• Lee M
• Yu DW
• Hong MY

• KMID: 2165027
• DOI: http://doi.org/10.5946/ce.2015.081

Abstract

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.

Keyword

Hemobilia; Delayed; Cholangiopancreatography, endoscopic retrograde; Perforation; Stents

MeSH Terms

Bile Ducts
Cholangiopancreatography, Endoscopic Retrograde
Embolization, Therapeutic
Hemobilia*
Hemorrhage
Humans
Plastics*
Stents*
Plastics

Figure

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  Fig. 1. (A, B) Abdominal non-enhanced computed tomography shows 15 mm-sized calcified stone in common bile duct (black arrow) and surgical clips are seen at the level of common haptic duct (white arrow).

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  Fig. 2. Post-endoscopic retrograde cholangiopancreatography. (A) Chest radiography shows a large pneumoperitoneum under the right hemidiaphragm and nasobiliary drainage tube is also seen in the common bile duct is (black arrow) with air-biliarygram in the right anterior hepatic duct. (B) Two plastic biliary stents (one pigtail type [white arrow], the other straight type) are deeply located into the right hepatic duct.

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  Fig. 3. (A, B) Emergent upper gastrointestinal endoscopy shows profuse active bleeding in the duodenum and the identified source of bleeding was the papillary orifice (white arrow), which is consistent with hemobilia.

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  Fig. 4. Transarterial angiogram via celiac artery. (A) The left panel shows the extravasation of contrast material in the right posterior hepatic artery (RPHA), which is suggestive for active bleeding. (B) Cholangiogram of the right posterior hepatic duct is obtained through the arteriobiliary fistula near the RPHA. (C) After two sessions of embolization by using multiple coils, no further contrast extravasation is seen in right panel.

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