Clinical Case Summary
Introduction: The most common complications of ERCP include acute pancreatitis, post-sphincterotomy bleeding, and intestinal perforation. Traumatic arterio-biliary fistulas, although rare, have been reported following manipulation. This case presents severe haemorrhage secondary to an arterio-biliary fistula.
Case Report: A 61-year-old male, chronic alcoholic with chronic liver disease (BCLC-B) and distal bile duct stricture of filarial aetiology, was admitted for biliary stent replacement. Post-procedure, the patient developed worsening clinical parameters, including abdominal pain, leucocytosis, and elevated cholestasis markers. Imaging revealed the proximal end of the stent was in the cystic duct, requiring a second ERCP for repositioning.
The patient's condition deteriorated with severe acute cholangitis, haemorrhagic rectal bleeding, and haemodynamic instability. CT showed further biliary dilatation and haematic content within the bile ducts. A third ERCP was performed to remove clots and place a covered metallic stent to control the bleeding. Despite this, haemorrhage persisted. CT-angiography revealed a 9 mm pseudoaneurysm from the pancreaticoduodenal arcade and pancreatic artery (Figure 1). Selective embolisation was successful (Figure 2), with follow-up confirming no further aneurysm filling (Figures 3 and 4).
Discussion: Arterio-biliary fistulas are typically iatrogenic or traumatic, often following biliary or hepatic procedures like liver biopsy or cholecystectomy. Post-ERCP incidence is rare, with only three reported cases. Diagnosis requires high clinical suspicion and angiography. Fistulas can cause pseudoaneurysms, which may lead to haemobilia, presenting as gastrointestinal bleeding. Management is multidisciplinary; conservative treatment is suitable for small, non-bleeding fistulas, while endoscopic or radiological interventions are used for severe cases. Early intervention is key to favourable outcomes.
References
1. Rai R. Potentially fatal haemobilia due to inappropriate use of an expanding biliary stent. World Journal of Gastroenterology. 2003;9(10):2377.
2. Berry R, Han J, Mohit Girotra, Tabibian JH. Hemobilia: Perspective and Role of the Advanced Endoscopist. 2018 Jul 12;2018:1–12.
3. Delayed Massive Hemobilia After Biliary Stenting. Endoscopy. 2003 Nov;35(11):976–7.
4. Siu, W. T., Chau, C. H., Ka Bo Law, B., Yau, K. K., Luk, Y. W., & KaWah Li, M. Non-operative management of endoscopic iatrogenic haemobilia: case report and review of literature. Acta gastro-enterologica Belgica. 2005;68(4): 428–431.
5. Panno, C., Gutiérrez, S. C., Echeverría, R., Garbe, C., Milocco, M., Ianniccillo, H., Valenzuela, M., Cubilla, A., Alvarez, F., & Alvarez, E. Hemobilia secundaria a pseudoaneurisma de la arteria hepática [Hemobilia secondary to hepatic artery pseudoaneurysm]. Acta gastroenterologica Latinoamericana. 2015;45(2):133–136.