Post written by Linda Zhang, MBBS, from the Department of Gastroenterology and Hepatology, St George Hospital, Kogarah, Australia.

This article discusses the management of hemobilia due to gallbladder malignancy in a frail, elderly patient with multiple comorbidities, which limited the available therapies.

Our patient was a 90-year-old female who presented with biliary obstruction and melaena. An ERCP confirmed the presence of hemobilia, and subsequent cross-sectional imaging indicated infiltrative gallbladder cancer as the cause. Her age and comorbidities precluded definitive therapy for the suspected malignancy. However, ongoing clinically significant melena necessitated treatment of the hemobilia. Her renal function prohibited the administration of contrast for radiological embolization. The video shows her ERCP and cholangioscopy during which active bleeding was confirmed to arise from the cystic duct and a fully covered self-expanding metal stent (FC-SEMS) was placed for hemostasis. She recovered well post-procedurally and was able to be discharged home for best supportive care. She had no further bleeding episodes at 4-month follow-up but died from progressive renal failure.

Our case highlights certain factors which are important when using FC-SEMS to treat hemobilia. First, the diameter of the common bile duct (CBD) is crucial as stent migration is seen in 10% of cases using FC-SEMS. In our patient, a normalized CBD diameter of 6 mm allowed the safe placement; however, it is important to note that significant CBD dilatation would preclude the use of biliary FC-SEMS. Second, our stent was not placed directly over the site of bleeding but rather to occlude the cystic duct orifice. Whilst the mechanism of hemostasis in tumor-related hemobilia is usually via direct compression, the mechanism in our case is less clear but possibly due to tamponade of the cystic duct orifice and, less likely, direct tumor or vascular compression. Finally, the use of FC-SEMS in malignant biliary obstruction may result in cholecystitis in around 8%, from cystic duct occlusion. We mitigated this risk with the use of prophylactic antibiotics and by limiting both cholangioscopic irrigation and contrast injection into the gallbladder.

This case highlights the utility of ERCP and cholangioscopy in the diagnostic workup for hemobilia. Whilst previous reports describe the use of SEMS to palliate malignant hemobilia by direct tumor compression, this case presents a novel technique of using a FC-SEMS to control hemobilia arising from a gallbladder malignancy.

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