Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent

Abstract

AIM:To highlight the fatal complication caused by expanding biliary stents and the importance of avoiding use of expanding stent in potentially curable diseases. METHODS:Arteriobiliary fistula is an uncommon cause of haemobilia. We describe a case of right hepatic artery pseudoaneurysm causing arteriobiliary fistula and presenting as severe malena and cholangitis, in a patient with a mesh metal biliary stent. The patient had lymphoma causing bile duct obstruction. RESULTS:Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolisation of the pseudo aneurysm successfully controlled the bleeding. CONCLUSION:Bleeding from the pseudo aneurysm of the hepatic artery can be fatal. Mesh metal stents in biliary tree can cause this complication as demonstrated in this case. So mesh metal stent insertion should be avoided in potentially benign or in curable conditions. Difficulty in diagnosis and management is discussed along with the review of the literature.Rai R, Rose J, Manas D. Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent. World J Gastroenterol 2003; 9(10)

Complications and diagnostic difficulties arising from biliary self‐expanding metal stent insertion before definitive histological diagnosis

“…Repeated episodes of stent occlusion necessitated removal of the stent, which was achieved with the aid of a suture‐cutting device. A similar report described a patient with a SEMS inserted before a confirmed histological diagnosis of non‐Hodgkin’s lymphoma, which responded to chemoradiotherapy 36 . The stent subsequently caused an arteriobiliary fistula leading to melaena and cholangitis.…”

“…A similar report described a patient with a SEMS inserted before a confirmed histological diagnosis of non-Hodgkin's lymphoma, which responded to chemoradiotherapy. 36 The stent subsequently caused an arteriobiliary fistula leading to melaena and cholangitis. Egan and Baron described the case of a 76-year-old woman with obstructive jaundice secondary to a 2-cm ampullary mass seen on ERCP.…”

An unusual cause of haemobilia - beware the forgotten stent!

“…Metal biliary stents have previously been reported to cause haemobilia. Rai et al (8) postulated that a metal stent may have led to the development of a pseudoaneurysm of the right hepatic artery with subsequent haemorrhage into the biliary tree. Biliary stents have also been reported to cause gastrointestinal haemorrahage by erosion through the mucosa of the duodenal wall (9,10).…”

Hemobilia

“…Such bleeding may occasionally reflux from the duodenum into the biliary tree, and cause obstruction to the latter [48]. ERCP has also caused hemobilia in cases of portal biliopathy, metal biliary stenting, and intrahepatic vascular anomalies associated with hereditary hemorrhagic telangiectasia [49,50]. Although up to 10% of endoscopic and percutaneous intraductal lithotripsies are reported to be complicated by hemobilia [23•], this has not been the experience of the authors with ERCP.…”