Umair M. Nasir
Rutgers New Jersey Medical School
A 69-year-old man with chronic alcoholic pancreatitis initially presented with nausea, vomiting, and colicky RUQ pain. CTA abdomen/pelvis revealed pancreatic head enlargement and CBD dilatation with no evidence of HPA (CT Figure A). ERCP revealed severe CBD stricture, prompting sphincterotomy and dilation with placement of two plastic stents in the CBD (Endo Figure A). Five months later, he returned with two days of nausea and hematemesis. ERCP revealed HB. Extraction of the first stent resulted in brisk bright red blood from the ampulla, and immediate stent replacement tamponade the bleeding (Endo Figure B). CTA abdomen/pelvis revealed appropriately placed biliary stents adjacent to a right HPA (CT Figure B), which was treated with coil embolization (Angiogram Figure A). Two months later, both stents were extracted and replaced with a single, covered metal stent. Four months after that, due to proximal migration, the metal stent was extracted and replaced with two plastic stents (Endo Figure C). One week after the stent exchange, he again presented with nausea and hematemesis. Fluoroscopy revealed expansion of the right HPA with adjacent biliary stents (Angio Figure B), and successful coil embolization was performed. Two months later, both plastic stents were extracted without replacement and CBD stricture was managed with sphincterotomy and dilation.
Percutaneous and surgical interventions of the liver and gallbladder, including endoscopic intrahepatic ductal dilation, can rarely cause hepatic artery injury leading to HPAs. Our case demonstrates the potential for HB due to HPA formation following plastic stent placement. Hemodynamically stable patients with HB should undergo radiographic, endoscopic, and angiographic evaluation followed by selective embolization or surgery. A multidisciplinary approach is required to reduce the mortality and morbidity in such patients.
CT Figure A: Coronal image of CTA abdomen/pelvis revealing stable heterogeneous enlargement of the pancreatic head and the right hepatic artery without any vascular malformation.
CT Figure B: Coronal image of CTA abdomen/pelvis revealing heterogeneous enlargement of the pancreatic head decreased in size to prior imaging. Interval development of a right hepatic artery pseudoaneurysm.
Angiogram Figure A: Angiogram of the proper hepatic, right hepatic, and left hepatic artery, revealing right hepatic artery pseudoaneurysm with adjacent biliary stents.
Angiogram Figure B: Angiogram of the right hepatic artery, revealing prior embolization coils in place. Expansion of right hepatic artery pseudoaneurysm noted with adjacent biliary stents
Endoscopy Figure A: Endoscopy revealing two 10 Fr 9 cm straight plastic stents in place with no evidence of hemobilia.
Endoscopy Figure B: Endoscopy revealing hemobilia and old 10 Fr 9 cm straight plastic stents adjacent to a new similarly sized plastic stent, with no evidence of active brisk bleeding.
Endoscopy Figure C: Endoscopy revealing proximal migration of the covered metal stent.
Umair Nasir indicated no relevant financial relationships.
Aashka Parikh indicated no relevant financial relationships.
Jeffrey Paer indicated no relevant financial relationships.
Pratibha Surathi indicated no relevant financial relationships.
Qi Yu indicated no relevant financial relationships.
Kathleen Pergament indicated no relevant financial relationships.
Sushil Ahlawat indicated no relevant financial relationships.