A HOME-MADE BILIARY SENGSTAKEN TUBE AS A TEMPORIZING STRATEGY FOR MASSIVE BLEEDING SECONDARY TO ARTERIO-BILIARY FISTULA (ABF)

ABF are an infrequent complication of EUS-guided biliary drainage. Angiography with embolization is the treatment of choice, but it is not always immediately available. A novel endoscopic method to temporize severe bleeding from ABF is reported here.

A patient with Roux-en-Y distal gastrectomy had EUS-guided hepaticogastrostomy (EUS-HGS) with a fully-covered self-expandable metal stent (SEMS) as entry port for laser lithotripsy under transgastric cholangioscopy to treat CBD stones. 4-months following HGS the patient presented with severe upper GI bleeding and shock.

At upper endoscopy, bleeding was seen around the edges of the HGS. The SEMS was removed and transgastric cholangioscopy confirmed bleeding from SEMS-induced pressure on the liver end. A longer SEMS was placed and bleeding was arrested for 4-hours. At repeat upper endoscopy, massive bleeding from the HGS was again noted. A guidewire was passed into the CBD through the HGS-SEMS, and a 12-mm balloon passed over-the-wire distal to the SEMS and inflated. Bleeding stopped immediately. To remove the gastroscope from the balloon catheter, the balloon luer-lock piece had to be cut. The balloon catheter was clamped with forceps and ligatures. Endoscopy confirmed stable inflation. The patient remained 18-hours without rebleeding. Angiography documented a high-flow ABF from the right hepatic artery to the biliary SEMS. Coil embolization was effective in arresting bleeding.

Although rare, severe bleeding following EUS-HGS is almost invariably caused by ABF. Prompt recognition and arterial embolization are mandatory. An inflated balloon dilator is a relatively simple intervention that can successfully bridge the patient in cases where embolization is not immediately available.