Post written by Kyosuke Goda, MD, and Yusuke Hashimoto, MD, MMA, from the National Cancer Center, Hospital East Hepatobiliary Pancreatic Oncology, Chiba, Japan.

A 68-year-old man with a history of diabetes mellitus was referred to our institution for evaluation of a bulky tumor in the head of the pancreas.

Abdominal CT revealed a large hyperdense tumor obstructing the distal bile duct, with no evident dilatation of the pancreatic duct. ERCP showed distal biliary compression, and a covered self-expandable metallic stent (SEMS) was inserted for the relief of obstructive jaundice. EUS-guided fine-needle biopsy displayed evidence of a plasma cell tumor.

Even though biliary drainage was achieved with transpapillary SEMS and EUS-guided hepaticogastrostomy, the patient went into shock with overt biliary bleeding. We performed peroral digital cholangioscopy for investigating the source of the hemobilia and diagnosed the hemobilia as originating from the varices in the left portal venous system. The patient was referred for interventional radiology and underwent main portal venous stenting to reduce the portal venous pressure.

Diagnosis of the bleeding source is usually made by arterial- and/or portal-phase CT findings. The patient did not show any extravasation on CT scan. We suspected several possible etiologies to explain the hemobilia, from iatrogenic biliary interventions to portal hypertensive cholangiopathy or biliary ulceration from the tumor. Eventually, digital cholangioscopy proved to be of great value to determine the source of the bleeding.

Hemobilia is defined as bleeding into the biliary tree, varying in severity from mild to life-threatening, depending on the cause of bleeding. Etiologies include biliary tract tumor, cholangiopathy secondary to cirrhosis, prosthesis, or invasive procedures associated with endoscopic biliary intervention. Diagnosis of the bleeding source is usually made by arterial- and/or portal-phase CT findings. Identifying the source of hemobilia potentially leads to an appropriate judgment and intervention.

Fortunately, the patient survived the hemobilia, and the tumor dramatically responded to chemotherapy. He has survived for 4 years with tumor-free status. Advanced biliary imaging using peroral digital cholangioscopy is worthy of evaluating hemobilia of the unknown source, as the etiologies vary.

A, CT image showing a bulky tumor in the head of the pancreas. B, A 22-gauge EUS-FNA needle was used to puncture the bulky tumor in the head of the pancreas. C, Radiograph showing endoscopic transpapillary biliary drainage with a covered self-expandable metallic stent. D, CT image showing an increase in the size of the mass as compared with a month earlier. E, The mass was found to compress the horizontal portion of the duodenum. F, Radiograph showing EUS-guided hepaticogastrostomy with a plastic stent. G, CT image showing the bulky mass causing focal compression of the base of the left portal vein (blue arrows). H, Multiple varices formed in the left portal venous system.

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