The Vanishing Act: Inadvertent Portal Venous Cannulation During ERCP

A 44-year-old male presented with worsening jaundice, pruritus, and loss of appetite and weight over 3 months. Magnetic resonance imaging revealed growth in the periampullary region, characterized by dilated common bile and pancreatic ducts. Due to significant pruritus and jaundice, endoscopic retrograde cholangiopancreatography (ERCP) and biliary drainage were planned. During side-viewing endoscopy, the papilla was replaced by an ulcerative proliferative growth. The common bile duct was cannulated through this growth, and a guidewire was advanced into the intrahepatic biliary radicle. To confirm biliary cannulation, biliary aspiration was attempted, which yielded only fresh blood ([Fig. 1A]). Portal venous cannulation was suspected; therefore, 2 mL of contrast was injected, opacifying the portal vein ([Fig. 1B]), which vanished within 5 seconds ([Fig. 1C]). The sphincterotome was withdrawn without any evidence of haemobilia through papillary growth. Biliary cannulation was reattempted and confirmed by aspirating bile ([Fig. 1D]), and a plastic stent was placed to drain bile. The patient had no bleeding episodes or drop in hemoglobin, and his jaundice improved. He was discharged in stable condition.

Fig. 1 Inadvertent portal venous cannulation during ERCP. (A) Bloody aspiration while confirming biliary cannulation. (B) Contrast injection demonstrating a portal venogram. (C) Immediate washout of contrast from the portal vein within 5 seconds. (D) Confirmation of biliary cannulation by aspiration of bile.

Practical Implications for Endoscopists

• ERCP-related portal venous cannulation is an extremely rare complication, with few cases reported. Portal vein cannulation should be considered when there is difficulty advancing the sphincterotome, especially in cases of distal malignant obstruction.

• The presence of bloody aspirate and rapid contrast washout on fluoroscopy generally confirms this complication.[1] [2]

• Portal and hepatic venous trauma after ERCP can cause fatal pulmonary and cerebral air and/or bile embolism; however, mortality after only portal venous cannulation has not been reported.[3]

• Most cases can be managed conservatively with safe outcomes. In cases of severe bleeding, balloon tamponade or stenting with a fully covered stent can be performed, and they rarely require surgery.[4]

Conflict of Interest

None declared.

Authors' Contributions

L.C.K. and R.T.R. were involved in the patient's care and collection of the data, V.V. contributed to conceptualization and the original draft of the manuscript, and S.S. contributed to supervision and final review of the manuscript.

Patient's Consent

Informed consent was obtained from the patient for the publication of her information and imaging.

• References

• 1 Taşar P, Kılıçturgay SA. Portal vein injury following endoscopic retrograde cholangiopancreatography: a case report. Ulus Travma Acil Cerrahi Derg 2023; 29 (03) 443-447
• 2 Lin PY, Wang SH, Tian YF. et al. Incidentally portal vein penetration during cannulation in endoscopic retrograde cholangiopancreatography: a case report. J Surg Case Rep 2023; 2023 (06) rjad298
• 3 Kennedy C, Larvin M, Linsell J. Fatal hepatic air embolism following ERCP. Gastrointest Endosc 1997; 45 (02) 187-188
• 4 Kalaitzakis E, Stern N, Sturgess R. Portal vein cannulation: an uncommon complication of endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2011; 17 (46) 5131-5132

Publication History

Article published online:
15 December 2025