Endobiliary radiofrequency ablation of an intraductal vessel in a patient with surgically altered anatomy

A 49-year-old man with a history of chronic pancreatitis following Whipple procedure presented with hematemesis and hematochezia. Enteroscopy revealed blood throughout the afferent and efferent limbs, with a clot at the hepaticojejunostomy anastomosis ([Fig. 1]). Two subsequent endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed to remove the blood clots ([Fig. 2]) and place biliary stents to manage the hemobilia. Owing to ongoing bleeding, the patient underwent empiric embolization of the left and right hepatic arteries. Despite these efforts, the patient’s bleeding persisted, with associated hemodynamic instability. After a multidisciplinary discussion, the patient was offered salvage endobiliary radiofrequency ablation (RFA).

Fig. 1 Blood clot overlying the hepaticojejunostomy anastomosis.

Fig. 2 Removal of blood clots from the hepaticojejunostomy during balloon sweeping.

An ERCP was performed using a standard adult colonoscope ([Video 1]). Upon biliary cannulation, the cholangioscope (SpyScope DS II; Boston Scientific, Marlborough, Massachusetts, USA) was advanced through the colonoscope. Examination of the left hepatic duct revealed an intraductal vessel with surrounding bloody material ([Fig. 3]). The RFA catheter (Habib; Boston Scientific) could not be advanced out of the colonoscope because of its length, necessitating exchange of the colonoscope for a therapeutic gastroscope. The RFA catheter was then advanced over the guidewire to the level of the vessel, and two applications of RFA (Effect 8, Power 10 watts) were performed for 90 seconds each. Repeat cholangioscopy demonstrated only partial ablation of the vessel, and two additional applications of RFA were required before sufficient ablation of the vessel was achieved ([Fig. 4]). Bilateral 10 Fr biliary stents were then placed, and there were no further episodes of bleeding during 14 months of follow-up.

Fig. 3 Intraductal visible vessel with signs of recent bleeding as viewed on cholangioscopy.

Fig. 4 Successful treatment on an intraductal visible vessel with radiofrequency ablation.

Video 1 Demonstration of radiofrequency ablation for treatment of an intraductal visible vessel resulting in hemobilia from a hepaticojejunostomy anastomosis.

Hemobilia, which is usually caused by traumatic, malignant, or iatrogenic etiologies, presents as challenge from both diagnostic and management standpoints [1]. We have previously demonstrated the use of RFA as a salvage treatment modality for treating hemobilia and this case reports its successful use in a patient with surgically altered anatomy [2] [3].

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Conflict of Interests

The authors declare that they have no conflict of interest.

• References

• 1 Zhornitskiy A, Berry R, Han JY. et al. Hemobilia: historical overview, clinical update, and current practices. Liver Int 2019; 39: 1378-1388
• 2 Linz CM, Modi RM, Krishna SG. A dual-modality approach of endobiliary radiofrequency ablation and self-expandable metal stent placement to control malignant hemobilia. Endoscopy 2017; 49: E21-E22
• 3 Han S, Krishna SG, Runge TM. Radiofrequency ablation for hemostasis of an intraductal visible vessel. Clin Gastroenterol Hepatol 2022;

Publication History

Article published online:
17 March 2023