Hemobilia due to arteriobiliary duct fistula is a rare complication of percutaneous
liver biopsy [1]
[2]
[3] typically presenting with jaundice, pain, and bleeding [4]. The role of endoscopic retrograde cholangiopancreatography (ERCP) is well established
[1]
[5]. We report two cases successfully treated with sphincterotomy and clot removal.
Case 1. A 45-year-old woman with a clinical diagnosis of cirrhosis underwent liver biopsy.
She had a past history of cholecystectomy. There was no evidence of any complication
shortly after the biopsy. After 5 days, although otherwise asymptomatic, she developed
jaundice (total bilirubin 5 mg/dL). Abdominal ultrasound showed a slightly dilated
common bile duct (CBD). She was referred for ERCP, which demonstrated mild dilation
of the CBD with a long longitudinal mobile filling defect ([Fig. 1]) corresponding to a large blood clot filling the whole duct.
Fig. 1 Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated mild dilation of
the common bile duct with a long longitudinal mobile filling defect suggesting the
presence of a blood clot.
After sphincterotomy the clot was retrieved using a balloon ([Fig. 2]).
Fig. 2 Endoscopic view of a clot being retrieved using a balloon after the sphincterotomy.
Cholangiography following intraductal clot removal demonstrated clearance of the filling
defect ([Fig. 3], [Video 1]).
Fig. 3 Occlusion cholangiogram revealing clearance of the bile duct.
Video 1 Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated mild dilation
of the common bile duct with a long longitudinal mobile filling defect suggesting
the presence of a blood clot. Sphincterotomy was performed and a large clot was retrieved
using a balloon. Final occlusion cholangiogram revealing clearance of the bile duct.
The patient recovered uneventfully with no further bleeding.
Case 2. A 37-year-old man with a past history of blood transfusion and elevated liver enzymes
underwent liver biopsy. Viral serology findings were negative and autoimmune disease
had also been disclosed. There was no evidence of early complications after the procedure.
Four days after the biopsy the patient presented with jaundice, fever, and severe
abdominal pain. Liver enzymes and bilirubin were slightly raised (total bilirubin
9.3 mg / dL). Abdominal CT scan revealed a mildly dilated biliary tree with the suggestion
of an arteriobiliary fistula ([Fig. 4], arrows).
Fig. 4 Abdominal CT scan showing a slightly dilated biliary tree with the suggestion of an
arteriobiliary fistula (arrows).
ERCP disclosed an enlarged major papilla obstructed by a blood clot ([Fig. 5 a]).
Fig. 5 a ERCP showed an enlarged major papilla obstructed by a blood clot. b Large blood clots were drained after sphincterotomy.
A large filling defect was present in the dilated CBD suggestive of biliary obstruction
resulting from hemobilia. When sphincterotomy was performed, large blood clots were
drained ([Fig. 5 b], [Video 2]).
Video 2 Duodenoscopy showed an enlarged major papilla obstructed by a blood clot. After sphincterotomy
was performed large blood clots were drained and a balloon was used to clear the biliary
tree.
The final occlusion cholangiogram demonstrated no further filling defects and absence
of a biliary fistula.
Endoscopy_UCTN_Code_CCL_1AZ_2AO
