Successful Hemostasis of Bleeding From Biliary Varices

Abstract

A 72-year-old man presented with melena. He had been receiving chemotherapy for gastric cancer with portal venous tumor thrombosis and had undergone biliary plastic stent placement for bile duct stenosis owing to liver metastasis. Dynamic computed tomography showed the portal collaterals forming varices around the common bile duct and extravasation of the contrast into the common bile duct and the duodenum ( Figure A). Esophagogastroduodenoscopy showed bleeding from the papilla of Vater ( Figure B). Bleeding from biliary varices (BV) was suggested and thus endoscopic retrograde cholangiopancreatography (ERCP) was performed. Cholangiography showed extramural compression of BV. Although the bleeding had stopped spontaneously, projectile hemobilia occurred after removal of the previously placed stent ( Figure C). We inserted a fully covered, self-expandable metallic stent and achieved hemostasis. No adverse events were associated with this procedure and no further bleeding occurred.BV are observed mostly in patients with extrahepatic portal vein obstruction. 1 Although most patients with BV are asymptomatic, several cases of bleeding from BV have been reported, which are related to ERCP procedures such as sphinctectomy 2 and stent removal. 3 We should consider bleeding from BV when gastrointestinal bleeding is detected in a patient with extrahepatic portal vein obstruction and recognize the possibility of rupture in ERCP. References 1. Chandra R, Kapoor D, Tharakan A, et al. Portal biliopathy.

Role of endoscopy in hepatology

“…Alternatively, sphincteroplasty via transpapillary large balloon dilatation can be preferred as it reduces the risk by a factor 2 [32] . Endoscopists should remain vigilant about periampullary or intraductal varices, as these may lead to severe and substantial bleedings, typically necessitating a covered transpapillary metallic stent for immediate hemostasis [33] .…”