Clinical Endoscopy

Portal cavernography during endoscopic retrograde cholangiopancreatography: from bilhemia to hemobilia: Rawad A. Yared, Paraskevas Gkolfakis, Arnaud Lemmers, Vincent Huberty, Thierry Degrez, Jacques Devière, Daniel Blero; Clin Endosc 2023;56(4):521-526. Published online January 5, 2023; DOI: https://doi.org/10.5946/ce.2021.276

Portobiliary fistulas are rare but may lead to life-threatening complications. Biliary plastic stent-induced portobiliary fistulas during endoscopic retrograde cholangiopancreatography have been described. Herein, we present a case of portal cavernography and recurrent hemobilia after endoscopic retrograde cholangiopancreatography in which a portobiliary fistula was detected in a patient with portal biliopathy. This likely indicates a change in clinical presentation (from bilhemia to hemobilia) after biliary drainage that was successfully treated by placement of a fully covered, self-expandable metallic stent.

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Recognition and management of stent malposition in the portal vein during endoscopic retrograde cholangiopancreatography: A case report
Rui Wu, Feng Zhang, Hao Zhu, Ming-Dong Liu, Yu-Zheng Zhuge, Lei Wang, Bin Zhang
World Journal of Gastrointestinal Endoscopy.2024; 16(7): 432. CrossRef

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Delayed Severe Hemobilia after Endoscopic Biliary Plastic Stent Insertion: Sung Hak Lee, Seung Goun Hong, Kyoung yong Lee, Pyung Kang Park, Sung Du Kim, Mahn Lee, Dong Wook Yu, Man Yong Hong; Clin Endosc 2016;49(3):303-307. Published online March 25, 2016; DOI: https://doi.org/10.5946/ce.2015.081

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Hemobilia is a rare gastrointestinal bleeding, usually caused by injury to the bile duct. Hemobilia after endoscopic retrograde cholangiopancreatography (ERCP) is generally self-limiting and patients will spontaneously recover, but some severe and fatal hemorrhages have been reported. ERCP-related bowel or bile duct perforation should be managed promptly, according to the type of injury and the status of the patient. We recently experienced a case of late-onset severe hemobilia in which the patient recovered after endoscopic biliary stent insertion. The problem was attributable to ERCP-related bile duct perforation during stone removal, approximately 5 weeks prior to the hemorrhagic episode. The removal of the stent was performed 10 days before the onset of hemobilia. The bleeding was successfully treated by two sessions of transarterial coil embolization.

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A rare incidence of a hepatic artery pseudoaneurysm following plastic biliary stent insertion
Toshihiko Motohara, Kensuke Yamamura, Shigenori Ueno, Hiroshi Takeno, Yasunori Nagayama, Eri Oda, Ryuichi Karashima, Nobuyuki Ozaki, Toshiro Masuda, Toru Beppu
Clinical Journal of Gastroenterology.2024; 17(2): 352. CrossRef
A Study on the Spectrum of Imaging Findings of Post-ERCP-Specific Complications: A Retrospective Descriptive Study
Ruchira Mukherji, Manoj Gopinath
Indian Journal of Radiology and Imaging.2024; 34(03): 422. CrossRef
Reduction of bleeding by cabozantinib in metastatic renal cell carcinoma with hereditary hemorrhagic telangiectasia
Satoshi Kitamura, Takuto Hara, Yasuyoshi Okamura, Tomoaki Terakawa, Koji Chiba, Jun Teishima, Yuzo Nakano, Hideaki Miyake
International Cancer Conference Journal.2024;[Epub] CrossRef
A Case of Endovascular Stenting for Biliary Bleeding from a Pseudoaneurysm of the Right Hepatic Artery Following Bile Duct Stenting
Hiroki Koga, Atsushi Miyoshi, Noriyuki Egawa, Shinya Azama, Kenji Kitahara
The Japanese Journal of Gastroenterological Surgery.2024; 57(11): 567. CrossRef
Delayed Hemobilia Caused by Penetration of Biliary Plastic Stent into Portal Vein
Jinhyong Kang, Yang Tae Park, Hyo Jung Kim, Jae Seon Kim
The Korean Journal of Pancreas and Biliary Tract.2022; 27(3): 135. CrossRef
Complications of endoscopic retrograde cholangiopancreatography: an imaging review
Dinesh Manoharan, Deep Narayan Srivastava, Arun Kumar Gupta, Kumble Seetharama Madhusudhan
Abdominal Radiology.2019; 44(6): 2205. CrossRef
Recurrent Bleeding from a Hepatic Artery Pseudoaneurysm after Biliary Stent Placement
Kenji Yamauchi, Daisuke Uchida, Hironari Kato, Hiroyuki Okada
Internal Medicine.2018; 57(1): 49. CrossRef
Transcatheter arterial embolization for iatrogenic bleeding after endoscopic ultrasound-guided pancreaticobiliary drainage
N.J. Lee, J.H. Shin, S.S. Lee, D.H. Park, S.K. Lee, H.-K. Yoon
Diagnostic and Interventional Imaging.2018; 99(11): 717. CrossRef
Hemobilia due to arteriobiliary fistula complicating ERCP for residual bile duct stone in a case of Mirizzi syndrome
Surendrakumar Mathur, Vinaykumar Thapar, Vasudev Chowda
Annals of Hepato-Biliary-Pancreatic Surgery.2017; 21(2): 88. CrossRef

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Two Cases of Xanthogranulomatous Cholecystitis and Gallbladder Cancer with Hemobilia: Jong Kyu Kwon, M.D., Dae Jin Kim, M.D., Hyun Uk Ryu, M.D., Soo Hwan Seol, M.D., Byung Sik Hwang, M.D., Jong Hun Park, M.D.^* and Kyung Rak Son, M.D.^†; Korean J Gastrointest Endosc 2011;42(6):428-432. Published online June 4, 2011

Abstract PDF: Hemobilia is a rare upper gastrointestinal (GI) bleeding phenomenon usually caused by trauma but may occur due to various liver and pancreatobiliary diseases. Causes related to gallbladder disease include vascular disorders, malignancy, polyps, heterotopic GI mucosa, acalculous inflammation, and most commonly gallstones. Most cases are treated with a cholecystectomy. If hemobilia is detected, efforts must be made to exclude malignancy because hemobilia develops from both benign and malignant disease. Particularly in gallbladder disease with hemobilia, the possibility of gallbladder carcinoma should be considered. We report two cases of hemoblia by endoscopic retrograde cholangiopancreatography and duodenoscopy, with a review of the literature. The first case was xanthoglanulomatous cholesystitis and the second case was gallbladder cancer disclosed by cholecystectomy.

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A Case of Hemosuccus Pancreaticus Mistaken for Hemobilia: Seung Hwa Lee, M.D., Dong Hee Koh, M.D., Seon Wook Park, M.D., Ji Youn Kim, M.D., Young Wook Kim, M.D., Hyun Joo Jang, M.D., Sea Hyub Kae, M.D. and Jin Lee, M.D.; Korean J Gastrointest Endosc 2009;39(6):389-392. Published online December 30, 2009

Abstract PDF: Hemosuccus pancreaticus is a rare cause of chronic and intermittent chronic gastrointestinal hemorrhage, and this condition cannot be easily detected by endoscopy. We report here on a 51-year-old woman with obstructive jaundice and a history of acute pancreatitis and chronic alcoholism. Abdominal computed tomography showed a dilated distal common bile duct. We performed endoscopic retrograde cholangiopancreatography to decompress the bile duct and we found a blood clot on the orifice of the ampulla of Vater. Hemobilia with massive bleeding was seen during the examination. Angiography for controlling the hemorrhage showed the pseudoaneurysm of the pancreaticoduodenal artery. Angiographic embolization was successful for controlling the arterial hemorrhage. The patient remained symptom-free and he was discharged without complications. (Korean J Gastrointest Endosc 2009;39:389-392)

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A Case of Polyarteritis Nodosa That Presented as Hemobilia: Joo Wook Sung, M.D., Yun Jeong Lim, M.D., Jae Hyun Kwon, M.D.*, Kyung Jo Kim, M.D.^† and Jin Ho Lee, M.D.; Korean J Gastrointest Endosc 2009;38(6):364-367. Published online June 30, 2009

Abstract PDF: Hemobilia is defined as hemorrhage into the biliary tract, and the patients with hemobilia present with abdominal pain, jaundice and gastrointestinal bleeding. The causes of hemobilia are traumatic or operative injury to the liver or bile ducts, intraductal rupture of the hepatic abscess or aneurysm of the hepatic artery. Cholecystitis can also develop in patients with hemobilia. Polyarteritis nodosa (PAN) is a multisystem, necrotizing vasculitis of the small and medium-sized muscular arteries and patients with this illness may present with fever, sweats, weight loss, severe arthralgia and myalgia. Mesentery artery involvement that can result in gastrointestinal hemorrhage, bowel infarction and perforation is rare, yet very serious in patients with PAN. We report here on a rare case of PAN that presented as hemobilia due to rupture of a hepatic arterial aneurysm. (Korean J Gastrointest Endosc 2009;38:364-367)

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A Case of Chronic Acalculous Cholecystitis Presenting as Hemobilia: Soo Han Kim, M.D.*, Seok Jeong, M.D.*, Don Haeng Lee, M.D.*^,‡, Joon Mee Kim, M.D.^†, Kye Sook Kwon, M.D.*, Hyung Gil Kim, M.D.*, Yong Woon Shin, M.D.* and Young Soo Kim, M.D.*; Korean J Gastrointest Endosc 2008;37(1):71-75. Published online July 30, 2008

Abstract PDF: Hemobilia is defined as the presence of blood in the biliary tract and gastrointestinal lumen, which is caused by a communication between the biliary tract and blood vessels. Most cases of hemobilia originating in the gallbladder are related to gallstones, or rarely related to acalculous cholecystitis. A 48-year-old woman presented to the hospital secondary to epigastric pain and melena, and endoscopic retrograde cholangiopancreatography revealed hemobilia originating in her gallbladder. After laparoscopic cholecystectomy was performed, pathologic examination of the gallbladder revealed chronic acalculous cholecystitis. Hence, we report a case of hemobilia caused by chronic acalculous cholecystitis. (Korean J Gastrointest Endosc 2008; 37:71-75)

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A Case of Hemobilia Caused by Clonorchiasis: Kyoung Won Yoon, M.D., Chang Hwan Park, M.D., Seok Cho, M.D., Seung Hwan Lee, M.D., Wan Sik Lee, M.D., Hyeun Soo Kim, M.D., Sung Kyu Choi, M.D. and Jong Sun Rew, M.D.; Korean J Gastrointest Endosc 2008;36(5):313-317. Published online May 30, 2008

Abstract PDF: Clonorchiasis is a trematodasis caused by ingestion of a raw fish that contains the infective cysts. In cases of early infection, the patients complained non-specific gastrointestinal symptoms, including anorexia, epigastric pain or diarrhea. In cases of long-standing infection, an association with gallstones, choledocholithiasis, cholangitis and cholangiocarcinoma has been reported. However, acute hemorrhagic complications of clonorchiasis are extremely rare. Herein, we report on a case of hemobilia that was caused by Clonorchis sinensis, and this was confirmed by operation. (Korean J Gastrointest Endosc 2008;36:313- 317)

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A Case of Acute Cholangitis with Intraluminal Gallbladder Hematoma after Percutaneous Liver Biopsy: Sang Hoon Lee, M.D., Tae Nyeun Kim, M.D., Jun Young Lee, M.D., Hee Jung Moon, M.D., Jong Ryul Eun, M.D., Byung Ik Jang, M.D.; Korean J Gastrointest Endosc 2007;35(4):277-280. Published online October 30, 2007

Abstract PDF: Percutaneous liver biopsy is valuable for making the diagnosis and follow-up of many liver diseases. Complications after ultrasonography-guided liver biopsy are rare, but a few serious complications have been reported. We report here on a 43-year-old man with acute cholangitis and gallbladder hematoma secondary to hemobilia; these occurred 4 days after performing ultrasonography guided percutaneous liver biopsy for the evaluation of multiple liver nodules. (Korean J Gastrointest Endosc 2007;35: 277-280)

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A Case of Hemobilia Caused by Calculous Cholecystitis: Chang Soo Choi, M.D., Geom Seog Seo, M.D., Meyoung Cho, M.D., Tae Hyeon Kim, M.D., Suck Chei Choi, M.D., Ki Jung Yun, M.D.* and Haak Cheoul Kim, M.D.; Korean J Gastrointest Endosc 2007;34(3):174-178. Published online March 30, 2007

Abstract PDF: Hemobilia is a status of bleeding into the biliary tract, which is caused by abnormal communication between the intrahepatic blood vessels and biliary tract, and is a rare cause of upper gastrointestinal hemorrhage. Most cases of the hemobilia originating in the gallbladder are related to gallstones. However, hemobilia is a rare complication of calculous cholecystitis. We report a case of hemobilia as a complication of calculous cholecystitis in a patient given continuous aspirin medication. (Korean J Gastrointest Endosc 2007;34:174⁣178)

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A Case of Non-traumatic Hemobilia due to Pseudoaneurysm of the Hepatic Artery: Gwon Hyun Cho, M.D., Jong Jun Lee, M.D., Sang Kyun Yu, M.D., Kwang An Kwon, M.D., Dong Kyun Park, M.D., Yeon Suk Kim, M.D., Yang Suh Ku, M.D., Yu Kyung Kim, M.D. and Ju Hyun Kim, M.D.; Korean J Gastrointest Endosc 2006;33(3):173-177. Published online September 30, 2006

Abstract PDF: Hemobilia is a cause of obscure gastrointestinal hemorrhage. Most cases have an iatrogenic or traumatic origin but cases of hemobilia with non-traumatic causes are rare. The non-traumatic causes of hemobilia are inflammation, gallstones, neoplasm and vascular lesions. Currently, various therapeutic options are available for hemobilia, and transarterial embolization is now the first line of intervention used to stop the bleeding of hemobilia, which shows a high success rate of approximately 80% to 100% with a lower morbidity and mortality rate than with surgery. We report a rare case of non-traumatic hemobilia caused by a pseudoaneurysm of the hepatic artery that was successfully treated with transarterial embolization. (Korean J Gastrointest Endosc 2006;33: 173⁣177)

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A Case of Hepatocellular Carcinoma Invading Intrahepatic Duct Complicated by Hemobilia: Soo-Jeong Cho, M.D., Ji Kon Ryu, M.D., Sun-Jung Myung, M.D., Cheol Min Shin, M.D., Dong Won Ahn, M.D., Su Jong Yu, M.D., Ji-Won Yu, M.D., Jin Ho Paik, M.D.*, Gyeong Hoon Kang, M.D.* and Hyo-Suk Lee, M.D.; Korean J Gastrointest Endosc 2005;31(4):278-280. Published online October 30, 2005

Abstract PDF: A seventyone-year-old male presented with sudden epigastric pain followed by jaundice and intermittent right upper abdominal pain. He was diagnosed as hepatocellular carcinoma 7 years ago, and has been treated with transarterial chemoembolization, percuaneous ethanol injection and segmentectomy. On admission, the level of serum bilirubin, amylase and lipase were 8.7 mg/dL, 560 IU/L, and 13,297 IU/L, respectively. Stool occult blood test was positive. Abdominal computed tomography revealed newly- appeared intraductal soft tissue mass with ductal dilatation. Endoscopic retrograde cholangiography demonstrated filling defects in the common hepatic and distal common bile duct (CBD). Endoscopic sphincterotomy was performed and the clots in the distal CBD were removed. An intraductal stent was inserted at the common hepatic duct. The obstructive jaundice and pancreatitis were resolved. Our case suggests that intraductal hepatocellular carcinoma may induce hemobilia as a possible cause of acute pancreatitis. (Korean J Gastrointest Endosc 2005;31:278⁣281)

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A Case of Hemobilia Caused by Chronic Acalculous Cholecystitis: Hyun A Oh, M.D., Tae Neyun Kim, M.D., Eun Ju Lee, M.D., Hyung Chul Lee, M.D., Jun Hwan Kim, M.D., Byung Ik Chang, M.D. and Heon Ju Lee, M.D.; Korean J Gastrointest Endosc 2005;31(3):198-203. Published online September 30, 2005

Abstract PDF: Hemobilia is a status of bleeding into the biliary tract and occurs when the communication between the biliary tract and blood vessels was injured. Almost all the hemobilia orginated in the gallbladder were related to gallstones and rarely it was reported to be associated with acalculous cholecystitis. A 61-year-old man visited due to continuous right upper quadrant pain and endoscopy revealed oozing blood around the ampulla of Vater. Eighteen days later, laparoscopic cholecystectomy was performed and pathologic examination of the resected gallbladder disclosed acalculous cholecystitis and no stone was found. We report a case of hemobilia with acalculous cholecystitis. (Korean J Gastrointest Endosc 2005;31:198⁣203)

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A Case of Hemobilia Caused by Chronic Acalculous Cholecystitis: Hyun A Oh, M.D., Tae Neyun Kim, M.D., Eun Ju Lee, M.D., Hyung Chul Lee, M.D., Jun Hwan Kim, M.D., Byung Ik Chang, M.D. and Heon Ju Lee, M.D.; Korean J Gastrointest Endosc 2005;31(3):198-203. Published online September 30, 2005

Abstract PDF: Hemobilia is a status of bleeding into the biliary tract and occurs when the communication between the biliary tract and blood vessels was injured. Almost all the hemobilia orginated in the gallbladder were related to gallstones and rarely it was reported to be associated with acalculous cholecystitis. A 61-year-old man visited due to continuous right upper quadrant pain and endoscopy revealed oozing blood around the ampulla of Vater. Eighteen days later, laparoscopic cholecystectomy was performed and pathologic examination of the resected gallbladder disclosed acalculous cholecystitis and no stone was found. We report a case of hemobilia with acalculous cholecystitis. (Korean J Gastrointest Endosc 2005;31:198⁣203)

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Two Cases of Hemobilia Associated with Common Bile Duct Stones: Jeong Ki Kim, M.D., Kwang Hyun Ko, M.D., Hyeuk Park, M.D., Hong Youp Choi, M.D., Sung Pyo Hong, M.D., Seong Gyu Hwang, M.D., Pil Won Park, M.D. and Gyu Sung Rim, M.D.; Korean J Gastrointest Endosc 2005;30(3):178-181. Published online March 31, 2005

Abstract PDF: Hemobilia is a disease caused by injury or conditions that cause the abnormal communication between intrahepatic blood vessels and biliary tract, resulting in leakage of blood into the biliary tract. In the past, trauma had been the most common cause of hemobilia. However, with the increasing invasive procedures in the hepatobiliary tract, iatrogenic origin has become the major cause of hemobilia. Also, non-traumatic etiologies of hemobilia include vascular malformation such as aneurysm, gallstone, inflammation, biliary tumor, hepatocellular carcinoma and coagulopathy. Among these non-traumatic etiologies, choledocholithiasis is a rare cause of hemobilia. The authors have experienced two cases of hemobilia caused by choledocholithiasis, which was diagnosed by abdominal ultrasonography, abdominal CT and duodenoscopy. Both patients were treated by the endoscopic sphincterotomy and stone removal with basket. (Korean J Gastrointest Endosc 2005;30:178⁣182)

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A Case of Hemobilia due to Gallbladder Carcinoma: Heok Soo Ahn, M.D., Byoung Sik Mun, M.D., So Ri Kim, M.D., Soo Teik Lee, M.D. and Seung Ok Lee, M.D.; Korean J Gastrointest Endosc 2003;27(3):171-174. Published online September 30, 2003

Abstract PDF: Gallbladder carcinoma is an uncommon neoplasm, and hemobilia caused by this disease is rare. We present a case of hemobilia in a patient with gallbladder carcinoma, which was recognized at forward duodenoscopy. A 42-year-old man visited our hospital due to intermmittent right upper quadrant pain. Duodenoscopy revealed blood clots with bile juice around the ampulla of Vater and the second portion of the duodenum. Endoscopic ultrasonography for the gallbladder showed a dumbell-shaped mass with a homogenous internal echogenicity on the body of the gallbladder. MR cholangiography showed a lobulated mass with low-signal intensity in the T1-weighted and T2-weighted images. Subsequently, laparoscopic cholecystectomy with regional lymph node dissection was performed, and adenocarcinoma was confirmed.

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자발성 담낭출혈로 인한 혈액담즙증 1예 ( A Case of Hemobilia Associated with Spontaneous Gallbladder Hemorrhage ): Korean J Gastrointest Endosc 1999;19(6):1005-1010. Published online November 30, 1998

Abstract PDF: Hemobilia is a hemorrhage into the biliary tract that may follow trauma (including surgical and percutaneous techniques in hepatobiliary system), aneurysms of the hepatic artery (and its branch), tumors of the biliary tract, hepatoma, inflammation, liver abscess, and gallstone disease. But, a case has not been reported involving of hemobilia associated with gallbladder hemorrhage without obvious predisposing factors or causes. A 62-year-old woman was admitted to Kyunghee Medical Center due to intermittent nausea, and right upper quadrant pain for 2 days before admission. She had no history of abdominal trauma. On the second and third day of her stay, she experienced melena of which the amount was about 300 ml. Abdominal ultrasonography revealed a gallbladder with a 8 mm sized cystic lesion attached to the fundus. Computed tomographic (CT) evaluation of the abdomen demonstrated a highly enhanced 7∼8 mm sized nodular mass in the lumen of the gallbladder. The gallbladder, cystic duct, and CBD were dilated due to the filling of blood clots or sludge material. An ERCP was performed and bleeding from the papilla of Vater was confirmed. Subsequently, emergent laparoscopic cholecystectomy was conducted. Pathologic evaluation revealed a grayish-red gallbladder that had a ruptured vessel. The ruptured vessel showed a severe hypertrophic state but there was no evidence of vasculitis, aneurysm, arterio-venous malformation, or malignancy. The case is here in reported of hemobilia associated with spontaneous gallbladder hemorrhage. (Korean J Gastrointest Endosc 19: 1005∼1010, 1999)

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직장 자궁내막증: 증례보고 및 국내문헌 고찰 ( Rectal Endometriosis: A Case Report of with a Clinical Analysis of Other Cases Reported in Related Korean Literature ): Korean J Gastrointest Endosc 1999;19(4):667-674. Published online November 30, 1998

Abstract PDF: Hemobilia is defined as a hemorrhage in the biliary tract and is most commonly associated with accidental or iatrogenic trauma. A case is herein reported of hemobilia developed in a hepatic artery aneurysm after biliary stenting was performed in patient with cholangiocarcinoma. A 63-year-old man was admitted with melena and had history of cholangiocarcinoma with an intraductal biliary stent. A hepatic artery angiography revealed two pseudoaneurysms at the common hepatic artery and right hepatic artery. Transarterial embolization with gelfoam was successfully received and hemobilia was not developed later. (Korean J Gastrointest Endosc 19: 671∼675, 1999)

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혈액응괴에 의한 폐쇄성황달을 동반한 간내담관암 1예 ( A Case of Hemobilia Developing Obstructive Jaundice by Blood Clots in a Patient with Cholangiocarcinoma ): Korean J Gastrointest Endosc 1993;13(2):419-423. Published online November 30, 1992

Abstract PDF: Cholangiocarcinoma is a rare tumor among all populations of the world and accounts for less than 2% of cancers found at autopsy and between 10% and 20% of all primary liver cancers. The tumor originates either from the intrahepatic small duct radicles(peripheral type) or the major hepatic ducts at or near the junction of the right and left hepatic ducts(hilar type). Included in the latter are the small intraduct carcinomas arising at the bifurcation of the hepatic ducts. (continue...)

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