Massive hemobilia following transpapillary bile duct biopsy treated by using a covered self-expandable metal stent

Severe hemobilia after a forceps biopsy is very rare [1] [2]. The management of uncontrolled hemobilia after endoscopic procedures includes percutaneous radiologic intervention or surgery [3] [4]. Recently, successful endoscopic hemostasis using covered self-expandable metal stents (CSEMS) for uncontrolled bleeding following sphincterotomy, stent removal, or papillary balloon dilation has been reported [3] [4] [5]. We report a case of massive hemobilia after a transpapillary forceps biopsy of the bile duct and successful endoscopic hemostasis with placement of a CSEMS.

A 51-year-old woman was admitted because of abdominal pain and jaundice. Abdominal CT showed cancer of the pancreatic head with a stricture of the common bile duct (CBD). Cholangiogram showed dilatation of the proximal bile duct with abrupt luminal narrowing of the CBD ([Fig. 1 a]). After endoscopic biliary sphincterotomy, transpapillary forceps biopsy was performed. A rat-tooth biopsy forceps (FB-39Q-1, Olympus, Tokyo, Japan) was used for tissue sampling at the constricted segment of the CBD ([Fig. 1 b]), but massive hemobilia occurred immediately afterwards ([Fig. 2], [Video 1]). To control the hemobilia, balloon tamponade with a controlled radial expansion balloon (Boston Scientific, Natick, MA, USA; 10 mm, 8 atm, 60 seconds) was attempted three times ([Fig. 3 a]). As the uncontrolled hemobilia continued, a partially covered SEMS (10 mm diameter, 8 cm long; Bonastent, Standard Sci-Tech, Seoul, Korea) was inserted to achieve hemostasis through compression exerted by the expandable stent ([Fig. 3 b]). Once the CSEMS had been placed, the hemobilia decreased and then stopped. The patient’s hemodynamic profile and vital signs were stable, and there was no further bleeding.

Fig. 1 a Cholangiogram showing luminal narrowing of the common bile duct with bile duct dilation. b Endoscopic transpapillary forceps biopsy was performed.

Fig. 2 After the transpapillary forceps biopsy, massive hemobilia developed.

After a forceps biopsy was taken, sudden massive hemobilia occurred, flowing out of the duodenum.

Fig. 3 a Fluoroscopy showing balloon tamponade performed in an attempt to control the hemobilia. b A partially covered self-expanding metallic stent was placed with nasobiliary drainage.

Complications related to transpapillary forceps biopsies are infrequent; usually, iatrogenic hemobilia is minor and can be controlled with conservative treatment [1]. Uncontrolled massive hemobilia after a transpapillary forceps biopsy has not previously been reported. Recently, placement of a CSEMS has been introduced as an effective means of endoscopic hemostasis for bleeding that could not be controlled with conventional methods [3] [4] [5]. If massive bleeding from the bile duct occurs during endoscopic retrograde cholangiopancreatography, hemostasis can be achieved promptly using a CSEMS, without radiological intervention or surgery. Endoscopic treatment using a CSEMS could be a useful way of providing effective hemostasis in selected patients with uncontrolled hemobilia of the extrahepatic bile duct.

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• References

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