Gastrointestinal Intervention 2017; 6(2): 148-150  https://doi.org/10.18528/gii170007
Pancreaticoduodenal artery pseudoaneurysm-induced hemobilia caused by a plastic biliary stent
Hong Joo Kim
Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, SungkyunkwanUniversity School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Korea. E-mail address:hongjoo3.kim@samsung.com (H.J. Kim).
Received: February 8, 2017; Accepted: February 8, 2017; Published online: July 31, 2017.
© Society of Gastrointestinal Intervention. All rights reserved.

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Abstract

Summary of Event

Melena with abdominal pain were developed in a patient who had undergone endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct stones removal and endoscopic retrograde biliary drainage (ERBD) using a plastic biliary stent. He subsequently underwent laparoscopic cholecystectomy. For the diagnosis and treatment of hemobilia caused by a plastic biliary stent, selective angiography for gastroduodenal artery with subsequent embolization for small pseudoaneurysm of pancreaticoduodenal artery was done successfully.

Teaching Point

A plastic biliary stent induced pseudoaneurysm can be a cause of hemobilia after ERCP with ERBD procedure. Selective angiography with embolization for bleeding pseudoaneurysm can be an effective treatment for this situation.

Keywords: Aneurysm, false, Angiography, Cholecystectomy, laparoscopic, Hemobilia, Stents
Event Details

A 73-year-old man with previous admission history of laparoscopic cholecystectomy (LC) due to calculous cholecystitis and endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct stones removal and endoscopic retrograde biliary drainage (ERBD) using a plastic biliary stent presented with melena and epigastric pain in the emergency department. He underwent upper gastrointestinal endoscopy and abdominal computed tomography (CT) scan with contrast enhancement in the emergency department and was confirmed to be hemobilia and distal migration of previously inserted a plastic biliary stent (Fig. 1). He had admitted to division of gastroenterology and underwent ERCP with common bile duct hematomas removal and ERBD change (Fig. 2). After the ERCP procedure procedure, hemobilia was controlled and hemoglobin levels were normalized. However, after 1 week of stable and no bleeding period, hemobilia and melena was recurred. Follow-up ERCP showed hemobilia (Fig. 3), and the patient underwent selective angiography for gastroduodenal artery using microcatheter and Meister guidewire (Asahi Intecc, Nagoya, Japan) with subsequent embolization for small pseudoaneurysm of pancreaticoduodenal artery with 1.5 mL of lipiodol (Guerbet Korea, Seoul, Korea) mixed with 0.5 mL of glue (Fig. 4). After this intervention, the patient was recovered from hemobilia and discharged thereafter 2 days of hospital admission.

Discussion

Hemobilia and vascular injuries are among the most important—albeit not necessarily the most common—complications of LC due to the high morbidity and mortality associated with this complication.1,2 Although, the most common causes of hemobilia after LC was iatrogenic arterial injury followed by ligation. Approximately 10% of all the reported cases of hemobilia after LC are secondary to iatrogenic hepatic artery pseudoaneurysm.3

If common bile duct stones with obstructive cholangitis were identified before LC, ERCP procedure with endoscopic sphincterotomy (EST), common bile duct stones removal and drainage procedure such as ERBD could be applied to the patient. A few case reports have described hepatic or intrahepatic artery pseudoaneurysm caused directly by a plastic biliary stent.46 In the present case, we inserted an 7-Fr plastic biliary stent (double pigtailed form) for the treatment of suppurative cholangitis associated with common bile duct stones, and the patient sequentially underwent LC for the treatment of calculous cholecystitis. After 8 weeks of ERBD insertion, the patient showed upper gastrointestinal bleeding due to hemobilia and subsequent selective angiography showed small pseudoaneurysm in pancreaticoduodenal artery. It is reasonable to assume that the mechanism of pancreaticoduodenal artery pseudoaneurysm in the present case was erosion of pancreaticoduodenal artery by the plastic biliary stent because the pseudoaneurysm was located at the critical proximal end of the migrated plastic biliary stent, implying a direct cause.

Prevention

Pancreaticoduodenal artery pseudoaneurysm induced by a plastic biliary stent is extremely rare and only one case in the present report was identified by literature searching. It would be reasonable to remove a plastic biliary stent if the symptoms and signs of suppurative cholamgitis were gone and especially in cases of distally migrated plastic biliary stent but was caught in the distal common bile duct.

Teaching Point

In cases of upper gastrointestinal bleeding after the insertion of a plastic biliary stent, a rare cause of hemobilia caused by hepatic artery or pancreaticoduodenal artery pseudoaneuryms formed by direct erosion of proximal end of a plastic biliary stent should be deemed in differential diagnosis of upper gastrointestinal bleeding. Appropriate diagnostic and therapeutic modalities such as hepatic angiography and embolization should be considered in these rare cases.

Figures
Fig. 1. The patient underwent upper gastrointestinal endoscopy (A) and abdominal computed tomography scan with contrast enhancement (B) in the emergency department and was confirmed to be hemobilia and distal migration of previously inserted a plastic biliary stent.
Fig. 2. The patient underwent endoscopic retrograde cholangiopancreatography with common bile duct hematomas removal and endoscopic retrograde biliary drainage (ERBD) change. (A) Blood clots were retrieved from the common bile duct using the Dormia basket and retrieval balloon. (B) In cholangiogram, a filling defect deemed to be a blood clot was noted in far distal common bile duct (CBD). Additionally, a small filling defect adherent to distal common bile duct wall deemed to be a pseudoaneurysm (arrows) was also noted in far distal CBD, just the position where proximal end of a migrated plastic stent abutted to bile duct wall. (C) ERBD change was done.
Fig. 3. After 1 week of stable and no bleeding period, hemobilia and melena was recurred. Follow-up endoscopic retrograde cholangiopancreatography showed hemobilia.
Fig. 4. The patient underwent selective angiography for gastroduodenal artery using microcatheter and Meister guidewire (Asahi Intecc, Nagoya, Japan) which revealed small pseudoaneurysm (arrows) of pancreaticoduodenal artery (A), and subsequent embolization for small pseudoaneurysm of pancreaticoduodenalartery with 1.5 mL of lipiodol (Guerbet Korea, Seoul, Korea) mixed with 0.5 mL of glue was done successfully (B).
References
  1. Sandblom, P, Saegesser, F, and Mirkovitch, V (1984). Hepatic hemobilia: hemorrhage from the intrahepatic biliary tract, a review. World J Surg. 8, 41-50.
    Pubmed CrossRef
  2. Connor, S, and Garden, OJ (2006). Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg. 93, 158-68.
    Pubmed CrossRef
  3. Merrell, SW, and Schneider, PD (1991). Hemobilia--evolution of current diagnosis and treatment. West J Med. 155, 621-5.
    Pubmed KoreaMed
  4. Wolters, F, Ryan, B, Beets-Tan, R, and Dejong, C (2003). Delayed massive hemobilia after biliary stenting. Endoscopy. 35, 976-7.
    Pubmed CrossRef
  5. Inoue, H, Tano, S, Takayama, R, Nimomiya, K, Nishikawa, K, and Katurahara, M (2011). Right hepatic artery pseudoaneurysm: rare complication of plastic biliary stent insertion. Endoscopy. 43, E396.
    CrossRef
  6. Chun, JM, Ha, HT, Choi, YY, Hwang, YJ, Heo, J, and Ryeom, HK (2016). Intrahepatic artery pseudoaneurysm-induced hemobilia caused by a plastic biliary stent after ABO-incompatible living-donor liver transplantation: a case report. Transplant Proc. 48, 3178-80.
    Pubmed CrossRef


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