A 65-year-old woman was referred to our hospital for thoracic spine
metastasis. She had undergone embolization 8 years ago for hemobilia caused by
a pseudoaneurysm in the right hepatic artery, which had developed after
cholecystectomy with T-tube choledochostomy. Laboratory studies revealed
alanine aminotransferase 510 IU/L, total/direct bilirubin
3.69/3.22 mg/dL, alkaline phosphatase 496 U/L, and
γ-glutamyltransferase 704 U/L. Abdominal computed tomography showed
a high-density coil at the hepatic hilum, compatible with pseudoaneurysm after
coil embolization, and marked dilatation of the bilateral intrahepatic bile
ducts ([Fig. 1]).
Fig. 1 High-density coil at the
hepatic hilum (arrow), compatible with a pseudoaneurysm after coil embolization
and marked dilatation of the intrahepatic bile duct in an older woman with
history of hemobilia.
Percutaneous transhepatic biliary drainage (PTBD) was carried out
because of obstructive jaundice. Endoscopic retrograde cholangiopancreatography
revealed dilatation of the intra- and extrahepatic bile ducts with amorphous
filling defects in the upper part of the common bile duct (CBD), and five
microcoils around the hepatic hilum ([Fig. 2]).
Fig. 2 Dilated intra- and
extrahepatic bile ducts with amorphous filling defects visualized in the upper
part of the common bile duct. Five microcoils around the hepatic hilum and the
percutaneous transhepatic biliary drainage catheter are also seen.
Endoscopic papillary balloon dilation (EPBD) was carried out, and a
Dormia basket was inserted and several mixed CBD stones extracted ([Fig. 3]).
Fig. 3 Endoscopic papillary
balloon dilation followed by insertion of a Dormia basket to remove a microcoil
(a) and several common bile duct stones (b).
A microcoil was found inside a fragment of a removed stone ([Fig. 4]).
Fig. 4 A microcoil within a
fragment of a removed stone.
Following this, the PTBD was removed and the patient discharged in a
relatively stable condition.
Hemobilia most often is due to iatrogenic causes and accidental
trauma, followed by gallstones, inflammation, vascular malformations, and
tumors [1]. The common symptoms are upper
gastrointestinal hemorrhage, upper abdominal pain, and jaundice. To our
knowledge, there has been only one prior report of hemobilia caused by hepatic
artery pseudoaneurysm after T-tube choledochostomy [2].
Mechanical compression of the bile duct mucosa and the adjacent part of the
hepatic artery by the T-tube may lead to blood vessel erosion and formation of
a pseudoaneurysm. Migration of coils into the bile duct through a small
arterial–biliary fistula after embolization of a hepatic artery
pseudoaneurysm is a rare complication [3], and may
trigger or exacerbate the formation of CBD stones, with cholangitis.
Endoscopy_UCTN_Code_CCL_1AZ_2AI
