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Print version ISSN 1130-0108
Rev. esp. enferm. dig. vol.104 no.2 Madrid Feb. 2012
LETTERS TO THE EDITOR
Endovascular treatment of iatrogenic hemobilia
Tratamiento endovascular de hemobilia iatrogénica
Key words: Arterio-biliary fistula. Hemobilia. Endovascular. Embolization.
Palabras clave: Fístula arteriobiliar. Hemobilia. Endovascular. Embolización.
We report the case of a 62-year-old Caucasian male, with surgical duodenocephalic pancreatectomy in April 2008 due to an intraductal mucinous-papillary neoplasm of the pancreatic head, who, in October 2008, was admitted because of a cholangitis secondary to a stenosis of biliary anastomosis treated by percutaneous transhepatic dilatation and biliary drainage. Two weeks later, the patient arrived at the emergency room in hypovolemic shock status secondary to severe hematemesis. An oral endoscopy failed to demonstrate the source of bleeding, so a liver angio-computer tomography (angioCT) was obtained. The liver angio-CT showed an extravasation of contrast in the right hepatic lobe (Fig. 1). An angiography revealed a pseudoaneurysm in a small arterial branch of the hepatic artery with an artery-biliary fistula (Figs. 2 and 3). We performed a successful embolization with coils (Fig. 4). Currently, the patient has had no complications related to transarterial embolization during follow-up.
Percutaneous procedures on the biliary tree are now considered essential to the management of biliary diseases. Hemobilia as a manifestation of venous or arterial vascular injury is among the complications associated with these procedures. Its incidence, although low, is rising due to increased percutaneous procedures on the liver and the bile duct with rates of 19-32% of injury vessel after transhepatic percutaneous drainage.
Arteriobiliary fistula secondary to hepatic artery pseudoaneurysm has been described as a very uncommon cause of hemobilia. The first case was reported in 1981. The diagnosis is difficult and should be suspected in a patient with upper gastrointestinal bleeding, hematemesis, or shock hypovolemic when a trauma or a procedure on the biliary tree was performed. Hemobilia is usually mild and self-limited.
Angiography is the gold standard today. The capacity to locate the source of bleeding (> 90% in some series) and the potential therapeutic possibilities with success rates of 80-100% and a morbidity comparable to open surgery have relegated the latter to cases of massive hemobilia that is not controlled by transarterial embolization (TAE), cholecystitis, and sepsis.
José M. Lorente-Herce1, Francisco Diéguez-Rascón2, Guillermo Núñez de Arenas-Baeza2,
Macarena Márquez-Muñoz1, Francisco J. Jiménez-Vega1 and José V. González-Herráez2
1UGC Enfermedades Digestivas. 2Servicio de Angiología y Cirugía Vascular. Hospital Universitario Virgen de Valme. Sevilla, Spain
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