Biliary stent for hemobilia caused by portal biliopathy

Mahesh Kumar Goenka, MD, DM, FACG, FASGE from the Institute of Dr. GoenkaGastroenterology, Department of Interventional Radiology at Apollo Gleneagles Hospitals in Kolkata, India shares this VideoGIE case “Fully covered self-expandable metal biliary stent for hemobilia caused by portal biliopathy.”

Overt bleeding from an ampulla after plastic biliary stent removal in portal biliopathy is a life threatening adverse event. A 22-year-old male presented with cholangitis with h/o biliary stent placement one month earlier for obstructive jaundice due to portal biliopathy secondary to non-cirrhotic portal vein obstruction. ERCP was performed because of stent blockage, and the previously placed common bile duct (CBD) stent was removed with foreign body forceps followed by which there was a sudden spurt of torrential bleeding from the ampulla, suggesting a rupture of intraductal varices. There was 300 ml of blood loss on table.

The CBD was selectively cannulated, and a cholangiogram was obtained, which revealed filling of pericholedochal collaterals and the presence of multiple intracholedochal varices. To overcome this life-threatening bleed, Inj terlipressin 2mg was given intravenously and we deployed an 8-cm, fully covered self-expandable metal biliary stent (Boston Scientific, Natick, Mass), and homeostasis was achieved.

Figure 1Figure 1. A, Spurting of blood through the papilla after stent removal. B, Cholangiogram showing pericholedochal varices. C, Deployment of a fully covered self-expandable metal stent.

Elective lienorenal shunt surgery with devascularisation was performed 2 weeks later. The patient was discharged without any postoperative adverse events. The metal stent was subsequently removed. Emergency portal hypertensive surgery carries a high risk of mortality. Placement of a covered biliary metal stent seems to be a promising approach to achieve immediate hemostasis for bleeding from portal biliopathy. Metal stents have better tamponade and patency compared with plastic stents. They can act as a salvage therapy and a bridge to elective devascularization and shunt surgery.

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