Direct peroral cholangioscopic diagnosis and metal stent failure in a case of refractory arterial hemobilia

A 49-year-old man, recently treated for choledocholithiasis and cholangitis with successful stone extraction and nasobiliary drainage, presented with recurrent upper abdominal pain. He had a remote history of iron-deficiency anemia 30 years prior, reportedly cured. On admission, computed tomography (CT) showed inhomogeneous density at the distal common bile duct (CBD) and tortuous vascular shadows in the pancreatic head region ([Fig. 1]). Laboratory tests revealed severe anemia, elevated liver enzymes, and increased inflammatory markers. Recurrent choledocholithiasis and anemia relapse were initially suspected.

Fig. 1 CT showed a inhomogeneous density at the CBD and b tortuous vascular shadows in the pancreatic head region on admission.

The next day, he developed severe abdominal pain, hematemesis, and hypotension. Emergency upper endoscopy revealed large amounts of fresh blood in the stomach, and duodenoscopy confirmed oozing hemorrhage from the major papilla. ERCP demonstrated a dilated CBD filled with blood clots. Notably, direct peroral cholangioscopy enabled, for the first time, definitive visualization and diagnosis of a pulsatile arterial stump at the distal CBD as the bleeding source, indicating a gastroduodenal artery malformation ([Video 1]). A fully covered self-expandable metal stent (FCSEMS, 10 mm × 40 mm) was placed for tamponade ([Fig. 2]). However, rebleeding occurred 6 days later due to stent migration, necessitating replacement with a longer FCSEMS (10 mm × 80 mm), along with nasobiliary drainage and endoscopic clip fixation ([Fig. 3]).

Cholangioscopic view of a pulsatile arterial stump at the distal CBD.Video 1

Fig. 2 Initial FCSEMS placement (10 mm × 40 mm) for tamponade.

Fig. 3 Repeat ERCP with longer FCSEMS (10 mm × 80 mm), nasobiliary drainage, and clip fixation.

Selective angiography revealed a patchy vascular malformation in the gastroduodenal artery territory ([Fig. 4]), without obvious contrast extravasation. Embolization was performed on two branches of the gastroduodenal artery supplying the malformation. Nevertheless, a third bleeding episode occurred 7 days later. Repeat angiography demonstrated diffuse abnormal vessels in the splanchnic region, precluding further embolization. The patient ultimately underwent pancreaticoduodenectomy.

Fig. 4 Angiography showed a a patchy vascular malformation in the gastroduodenal artery area and b two supplying branches were embolized.

To our knowledge, this is the first reported case of arterial hemobilia definitively diagnosed by direct peroral cholangioscopy. While FCSEMS can be effective for hemobilia [1] [2], it may be inadequate for refractory arterial bleeding. Early surgical intervention should be considered when endoscopic and radiologic therapies fail [3].

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Publication History

Article published online:
22 September 2025

• References

• 1 Tanikawa T, Miyake K, Kawada M. et al. A case of successful endoscopic hemostasis with a covered self-expandable metal stent for the treatment of spurting hemobilia. VideoGIE 2025; 10: 146-149
• 2 Costa MVS, Aragão LV, Jesus JM. et al. Diagnosis and endoscopic treatment of hemobilia due to biliary angiodysplasia: A case report and literature review. Cureus 2023; 15: e50552
• 3 Liu X, Huang J, Tan H. et al. Hemobilia caused by pancreatic arteriovenous malformation: A case report and literature review. Medicine (Baltimore) 2018; 97: e13285