Post written by Nao Fujimori, MD, PhD, from the Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
Hemobilia is a rare but life-threatening adverse event related to pancreato-biliary diseases, transhepatic percutaneous, or endoscopic interventions. The rupture of the pseudoaneurysm after a plastic stent or self-expandable metallic stents (SEMSs) insertion or a plastic stent removal has been reported to induce massive hemobilia. However, hemobilia after SEMS removal is extremely rare. We here report a rare case of a patient with successful endoscopic tamponade using a fully covered SEMS for massive biliary bleeding from a pseudoaneurysm rupture during SEMS removal. A patient with advanced pancreatic head cancer was planned to exchange the SEMS due to stent occlusion. After an extraction of the SEMS using a snare through the scope, massive bleeding from the biliary tract was suddenly exacerbated, which resulted in a hemodynamic shock state within a few minutes. We promptly inserted a new SEMS for tamponade. The CT scan performed immediately after the endoscopic procedures revealed a 2-cm pseudoaneurysm in the pancreatic tumor, which was adjacent to the SEMS and was not evident on a CT 2 weeks ago. Subsequently, transcatheter arterial embolization was successfully performed for the pseudoaneurysm.
Removal of a SEMS is sometimes attempted in daily medical practice because of stent dysfunction. However, hemobilia can occur any time not only after the endoscopic insertion of plastic/metallic stents, but also during their extraction. Endoscopists must consider the rare possibility of massive hemobilia when attempting to remove SEMSs. During SEMS removal, it is necessary to have a new SEMS at hand.
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