Massive hemobilia following plastic stent removal in common bile duct cancer associated with primary sclerosing cholangitis (with video)

Abstract

Hemobilia is defined as bleeding into the biliary tract. Herein, we report a very rare case of massive hemobilia following plastic stent (PS) removal in common bile duct (CBD) cancer. A 72-year-old man with primary sclerosing cholangitis had undergone repeated insertion of a PS into the CBD. Biliary tract biopsy was performed based on suspicion of combined CBD cancer. Biopsy revealed poorly differentiated adenocarcinoma of the CBD. One month after the biliary tract biopsy, he was admitted for acute cholangitis, and endoscopic retrograde cholangiography was performed for the exchange of the PS. When one of the two biliary PSs was removed, spurting bleeding from the major papilla began abruptly. The massive bleeding caused the patient to be in a pre-shock state. A retrieval balloon catheter was compressed against the papilla for hemostasis. Although he was treated conservatively, the patient developed a bloody discharge. Upper gastrointestinal endoscopy revealed that the pulsatile bleeding beside the PSs started immediately after the removal of the coagula. Emergent contrast-enhanced computed tomography showed right hepatic artery aneurysm across the CBD. Therefore, transarterial embolization was performed. The patient’s post-therapeutic course was uneventful. He received chemotherapy, but died about a half year after hemobilia occurred.

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Correspondence to Hiroshi Miyamoto or Tetsuji Takayama.

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Hiroshi Miyamoto, Kumiko Tanaka, Fumika Nakamura, Takahiro Ikeda, Shinji Kitamura, Tetsuo Kimura, Koichi Okamoto, Masahiro Sogabe, Naoki Muguruma, Yoshimi Bando, and Tetsuji Takayama declare that they have no conflict of interest.

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All procedures followed have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments

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Informed consent was obtained from all patients for being included in the study.

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Video 1 When one of the two biliary plastic stents (PS) was removed using a snare, pulsatile bleeding from the major papilla began abruptly. During the bleeding, cannulation of the major papilla was performed and a guidewire was inserted into the biliary tract. A retrieval balloon catheter (B-V232P-B, Olympus Medical Systems, Tokyo, Japan) was compressed against the major papilla for hemostasis. After cessation of the bleeding from the major papilla, one PS (Flexima Biliary Stent with Delivery System, 7FrX7cm, BOSTON SCIENTIFIC CORP., Marlborough, MA, USA) was reinserted into the biliary tract (MPG 7972 KB)

Video 1 When one of the two biliary plastic stents (PS) was removed using a snare, pulsatile bleeding from the major papilla began abruptly. During the bleeding, cannulation of the major papilla was performed and a guidewire was inserted into the biliary tract. A retrieval balloon catheter (B-V232P-B, Olympus Medical Systems, Tokyo, Japan) was compressed against the major papilla for hemostasis. After cessation of the bleeding from the major papilla, one PS (Flexima Biliary Stent with Delivery System, 7FrX7cm, BOSTON SCIENTIFIC CORP., Marlborough, MA, USA) was reinserted into the biliary tract (MPG 7972 KB)

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Miyamoto, H., Tanaka, K., Nakamura, F. et al. Massive hemobilia following plastic stent removal in common bile duct cancer associated with primary sclerosing cholangitis (with video). Clin J Gastroenterol 12, 46–51 (2019). https://doi.org/10.1007/s12328-018-0888-7

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Keywords

  • Hemobilia
  • Plastic stent
  • Biliary tract biopsy
  • Primary sclerosing cholangitis
  • Common bile duct cancer