Delayed Severe Hemobilia Due to Bilio-venous Fistula After Percutaneous Transhepatic Biliary Drainage: Treatment With Covered Stent Placement

Abstract

Biliovenous fistula occurs due to development of a communication between hepatic duct and portal vein branches and is a rare complication of percutaneous transhepatic biliary drainage (PTBD). Most of them are self-limiting and only occasionally they need interventional management. Placement of biliary stent graft is a viable option. We present here a case of a 56-year-old male with carcinoma of gall bladder presenting with hemodynamic shock due to severe hemobilia after PTBD and treated successfully by biliary covered stent placement. ( J CLIN EXP HEPATOL 2016;6:241-243) P ercutaneous transhepatic biliary drainage (PTBD) is a standard treatment for improvement of liver functions and relief of jaundice in patients of malignant biliary obstruction.1 The technique has a technical success rate of more than 90% and clinical success rate of more than 75%.2,3 Complications associated with the procedure are seen in about 10% of patients and severe hemorrhage is seen in about 2.3% cases. 4,5 The etiology of severe after PTBD include arterio-biliary fistula, porto-biliary fistula, pseudoaneurysms and deranged coagulation parameters.6,7 Biliovenous fistula is a rare complication, seen in less than 0.5% cases, with few cases reported in literature. 4,[8][9][10][11][12] These cases are either managed conservatively or by radiological interventions in the form of balloon occlusion, coiling or covered stent placement depending on patient's hemodynamic status. 4,[8][9][10][11] We report a case of 56-year-old male with carcinoma of gall bladder, who developed bilio-venous fistula 3 weeks after PTBD and presented with features of hemodynamic shock and was managed by placement of biliary covered stent. CASE REPORTA 56-year-old male patient presented to gastrointestinal surgery out patient clinic with history of jaundice and pain abdomen for 2 months. Clinical examination revealed icterus. Per-abdominal examination was unremarkable. Ultrasonography was done, which showed a mass replacing the gall bladder with dilatation of bilobar intrahepatic biliary ducts. Subsequently, contrast enhanced computed tomography (CT) scan was done, which showed a heterogeneously enhancing mass replacing the gall bladder and involving the primary biliary and right secondary biliary confluence and right hepatic artery. Since, the volume of segments 2 and 3 of liver was small, surgery was deferred. The patient was referred for biliary drainage. Left sided PTBD was done and an 8.3-F ring biliary catheter (Cook, Bloomington) was inserted for initial internal/external drainage. One week later, the external end of the catheter was capped to allow internal drainage of bile. After two weeks, the patient presented to the emergency department with short history of blood leaking from the sides of catheter. On examination, the patient's blood pressure was 100/76 mmHg, pulse was 112/min and respiratory rate was 12/min. His liver function tests showed total bilirubin of 4.6 mg/dL, serum albumin of 1.5 g/dL, alkaline phosphatase of 350 IU, aspartate transaminase o...

Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments

“…Coiling within a central portal vein risks infarction of the subtended hepatic parenchyma. Other options include placing coils via the percutaneous drain access so that they straddle the site where the portal vein is traversed [ 37 ] and stent graft placement within the biliary system across the site of portal-biliary fistula [ 38 ]. If, as is more typically seen, the traversed vessel is a small peripheral PV branch, this is treated by tube upsizing, ensuring the side holes are central to PV branch.…”

Hemobilia due to porto-biliary fistula complicating endoscopic retrograde cholangiopancreatography after a recent liver transplantation

“…Early recognition is crucial for timely treatment and improved prognosis. In a suspected stent-related portal vein injury, a multidisciplinary strategy combining gastroenterology and radiology proved to be an effective and safe minimally invasive technique, avoiding catastrophic consequences (2,4,5). CT after a minimally invasive strategy combining gastroenterology and radiology revealing the fully-covered self-expanded metal stent placed in portal vein.…”

The experience of use of percutaneous transhepatic biliary drainages for early biliary complications after liver transplantation

“…15,26 PTBD-related bilioportal fistula is a rare complication, seen in less than 0.5% of cases, with few cases reported in the literature. 30 Nevertheless, if LT patients suffer PTBD-related vascular complications, their mortality rate will increase. 12,23,32,33 However, most of these reports discussed the use of PTBD in non-LT patients with nondilated IHBDs, and other procedures including T-tube drainage or temporary gall bladder drainages.…”