Iatrogenic hepatopancreaticobiliary injuries: a review

Biliary Complications Post Transjugular Intrahepatic Portosystemic Shunt in a Child With Portal Vein Cavernous Transformation

The transjugular intrahepatic portosystemic shunt is a rising interventional procedure with multiple indications and high technical success but with risks of biliary injuries, an underreported scenario. We present an 11-year-old patient with biliary injury with a leak, biloma formation, and biliary obstruction caused by the percutaneous procedure. Interventional radiology drainages addressed these complications by resolving the leak and biloma. These biliary complications in percutaneous procedures and their management are rarely reported in the medical literature, making their management not standard. We highlight drainage management and the importance of sharing it to add experience to this clinical scenario and encourage sharing cases with similar diagnoses.

A rare incidence of a hepatic artery pseudoaneurysm following plastic biliary stent insertion

Hepatic artery pseudoaneurysms have been reported to occur in approximately 1% of cases after metal stenting for malignant biliary obstruction. In contrast, only a few cases have been reported as complications after plastic stenting for benign biliary disease. We report a 61-year-old man with cholangitis who presented with a rare complication of hemobilia after implantation of 7 Fr double pigtail plastic biliary stents. No bleeding was observed approximately one month after biliary stent tube removal. Contrast-enhanced CT scan revealed a circularly enhanced lesion (5 mm in diameter) in the arterial phase at the tip of the previously inserted plastic bile duct stent. Color Doppler ultrasonography enhanced the lesion and detected arterial blood flow inside. He was diagnosed with a hepatic artery pseudoaneurysm. However, he had no risk factors such as prolonged catheterization, severe cholangitis, liver abscess, or long-term steroid use. Superselective transarterial embolization using two metal microcoils was successfully completed without damage to the surrounding liver parenchyma. If hemobilia is suspected after insertion of a plastic bile duct stent, immediate monitoring using contrast-enhanced computed tomography or Doppler ultrasonography is recommended.

Spectrum of Multidetector Computed Tomography Imaging Findings in Iatrogenic Abdominopelvic Injuries: A Comprehensive Pictorial Review

Iatrogenic injuries are unavoidable complications of surgeries and minimally invasive procedures. They are generally classified into vascular and nonvascular injuries and based on the time of injury into early and late injuries. Iatrogenic injuries, particularly vascular injuries, increase the mortality and morbidity, with prolongation of hospital-stay. Multidetector computed tomography (MDCT) is a highly sensitive, and often the first imaging modality in suspected iatrogenic injuries. This pictorial review elucidates the imaging considerations and appearances of iatrogenic injuries of the abdominopelvic organs on MDCT.

Case report: Recurrent hemobilia due to hepatic artery pseudoaneurysm mimicking gastrointestinal tract bleeding

Hemobilia, a rare form of upper gastrointestinal bleeding (UGIB), is a potentially fatal complication that usually occurs after iatrogenic hepatobiliary trauma. However, hemobilia is clinically challenging to diagnose and often gets too late to diagnose. We herein report a case of recurrent hemobilia due to hepatic artery pseudoaneurysm (HAP) that was initially misdiagnosed as gastrointestinal tract bleeding. However, the patient was treated successfully with percutaneous coil occlusion of the pseudoaneurysm. This case illustrates that hemobilia can present as a mimic of gastrointestinal tract bleeding, but this is often difficult to diagnose at first glance and often misleads clinicians, especially emergency physicians, into making an incorrect diagnosis. Familiarity with the clinical features of hemobilia can help raise clinical suspicion and facilitate the early diagnosis and treatment of hemobilia.

Role of Contrast-Enhanced Ultrasound in the Detection of Complications After Ultrasound-Guided Liver Interventional Procedures

The role of contrast-enhanced ultrasound (CEUS) in interventional ultrasound-guided procedures in the liver has been increasingly recognized. However, little is known about the capability of CEUS for diagnosing complications after liver biopsy and ablation with special regard to postprocedural hemorrhage. The aim of this Pictorial Essay is to present the CEUS features of a wide spectrum of vascular complications (with or without bleeding) and injuries of the surrounding abdominal and chest wall occurring after liver interventional procedures.

Hemobilia after bile duct resection: perforation of pseudoaneurysm into intra-pancreatic remnant bile duct: a case report

BACKGROUND

Hemobilia occurs mainly due to iatrogenic factors such as impairment of the right hepatic or cystic artery, and/or common bile duct in hepatobiliary-pancreatic surgery. However, little or no cases with hemobilia from the intra-pancreatic remnant bile duct after bile duct resection (BDR) has been reported. Here, we report a case of massive hemobilia due to the perforation of psuedoaneurysm of the gastroduodenal artery (GDA) to the intra-pancreatic remnant bile duct after hepatectomy with BDR.

CASE PRESENTATION

A 68-year-old male underwent extended right hepatectomy with BDR for gallbladder carcinoma. He presented with upper gastrointestinal bleeding 2 months after the initial surgery. Upper endoscopy identified a blood clot from the ampulla of Vater and simultaneous endoscopic balloon tamponade contributed to temporary hemostasis. Abdominal CT and angiography revealed a perforation of the psuedoaneurysm of the GDA to the intra-pancreatic remnant bile duct resulting in massive hemobilia. Subsequent selective embolization of the pseudoaneurysm with micro-coils could achieve complete hemostasis. He survived without any recurrence of cancer and bleeding.

CONCLUSION

Hemobilia could occur in a patient with BDR due to perforation of the pseudoaneurysm derived from the GDA to the intra-pancreatic remnant bile duct. Endoscopic balloon tamponade was useful for a temporal hemostasis and a subsequent radiologic interventional approach.

Platelet-rich fibrin can accelerate the healing of common bile duct anastomosis in a rat

Objectives

This study aimed to evaluate the effect of platelet-rich fibrin (PRF) concentrate on the bile duct anastomosis healing process in rats.

Material and Methods

Thirty male Sprague Dawley (SD) rats were used for the study. The animals were allocated into three groups: Group I Control Group (n=10): Anastomosis to the common bile duct (CBD) with a stent. Group II PRF Group (n=10): Anastomosis to the CBD with a stent and covered with PRF. Group III Sham Group (n=10): Preparation of the common bile duct, no anastomosis. The animals were followed up for 1 month, then sacrificed. Study parameters were adhesions around the anastomosis, thickness of the bridging bile duct tissue over the stent, and histopathologic examination of the bridging bile duct tissue.

Results

CBD anastomosis using a stent caused severe adhesion around the anastomosis, bridging bile duct tissues were weak and histopathologically, healing was incomplete in most of the control animals. However, PRF application significantly reduced the adhesions, increased the quality of the bridging bile duct tissues, and caused complete healing histologically.

Conclusion

PRF is an autologous, easily prepared membrane. The present study findings show that PRF prevents local complications and increases the healing capacity of the bile duct after CBD anastomosis. Therefore, it might be a new treatment option for preventing complications following common bile duct anastomosis in liver transplantation patients.

Hemobilia: Historical overview, clinical update, and current practices

Hemobilia refers to macroscopic blood in the lumen of the biliary tree. It represents an uncommon, but important, cause of gastrointestinal bleeding and can have potentially lethal sequelae if not promptly recognized and treated. The earliest known reports of hemobilia date to the 17th century, but due to the relative rarity and challenges in diagnosis of hemobilia, it has historically not been well-studied. Until recently, most cases of hemobilia were due to trauma, but the majority now occur as a sequela of invasive procedures involving the hepatopancreatobiliary system. A triad (Quincke's) of right upper quadrant pain, jaundice and overt gastrointestinal bleeding has been classically described in hemobilia, but it is present in only a minority of patients. Therefore, prompt diagnosis depends critically on a high index of suspicion based on a patient's clinical presentation and a history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors. Treatment of hemobilia depends on the suspected source and clinical severity and thus ranges from supportive medical care to urgent advanced endoscopic, interventional radiologic, or surgical intervention. In the present review, we provide a historical perspective, clinical update and overview of current trends and practices pertaining to hemobilia.

Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management

OBJECTIVE. The purposes of this article are to discuss a variety of liver masses that can present with hemorrhage, including their characteristic imaging features, and to propose a diagnostic approach. CONCLUSION. A broad spectrum of pathologic conditions can present as spontaneous hemorrhage within or surrounding the liver and may present acutely or as a chronic or incidental finding. Imaging characteristics and clinical history can often narrow the differential diagnosis and guide management.

Hemobilia: Etiology, diagnosis, and treatment☆

Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon but important cause of gastrointestinal hemorrhage. Reports of hemobilia date back to the 1600s, but due to its relative rarity and challenges in diagnosis, only in recent decades has hemobilia been more critically studied. The majority of cases of hemobilia are iatrogenic and caused by invasive procedures involving the liver, pancreas, bile ducts and/or the hepatopancreatobiliary vasculature, with trauma and malignancy representing the two other leading causes. A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding has been described (i.e. Quincke's triad), but this is present in only 25%-30% of patients with hemobilia. Therefore, prompt diagnosis depends critically on having a high index of suspicion, which may be based on a patient's clinical presentation and having recently undergone (peri-) biliary instrumentation or other predisposing factors. The treatment of hemobilia depends on its severity and suspected source and ranges from supportive care to advanced endoscopic, interventional radiologic, or surgical intervention. Here we provide a clinical overview and update regarding the etiology, diagnosis, and treatment of hemobilia geared for specialists and subspecialists alike.

Percutaneous Management of Biliary Enteric Anastomotic Strictures: An Institutional Review

Purpose

Stricture formation at the biliary enteric anastomotic site is a common complication due to fibrotic healing. Few therapeutic options are available for biliary-enteric anastomotic site stricture (BES) including new surgical reconstruction or percutaneous transhepatic biliary drainage followed by balloon dilation of BES or stent placement. The purpose of this study is to assess the technical success, complications and reintervention rate of percutaneous transhepatic balloon dilatation (PTBD) of BES after iatrogenic bile duct injuries (BDI).

Methods

A retrospective review of patients who underwent PTBD for benign resistant BES, previously treated for iatrogenic BDI, from December 2004 to January 2016 was performed. Diagnostic transhepatic cholangiogram was performed to assess the level of obstruction. BES was dilated using 8-12 mm diameter balloons followed by placement of eight to ten Fr internal-external drainage catheters, which were removed after three to six weeks post-PTBD cholangiogram. Follow-up by clinical assessment, liver function tests, and ultrasound was done. Fischer exact test was used to determine if there was a significant association between PTBD sessions and recurrent strictures.

Results

In total, 37 patients underwent 66 sessions of PTBD, including 10 (27%) males and 27 (73%) females. The mean age was 41.3 years (range 23–70 years). Out of these, 29 (78%) were treated with choledochojejunostomy and eight (22%) with hepaticojejunostomy. 100% technical success was achieved in all the PTBD sessions. Nineteen (51.3%) patients were treated with a single PTBD session. Mean follow-up time was 36 months (range 1–75 months). Eighteen (48.7%) patients needed reintervention, out of these, 11 (29.7%) were symptom-free after second session on three-year follow-up, three (8%) were symptom-free after the third session of PTBD. No significant difference was observed in risk of recurrent strictures after first and second PTBD sessions [18 (48%) vs. 7 (39%); p-value 0.495]. In four (11%) patients, the symptoms persisted and BES recurred even after third session and those were treated by placing metallic stent. In total, three (8.1%) patients got complicated with the stone formation; in two (5%) patients stone was successfully removed percutaneously and in one (3%) patient percutaneous attempt failed so it was followed by surgical removal.

Conclusion

PTBD is a safe and useful treatment option for benign BES for long-term symptom-free time-period. However, there is no significant difference in developing recurrent BES after PTBD sessions. Few patients with resistant strictures might require stent placement.

Recurrent Hemobilia Due to Right Hepatic Artery Pseudoaneurysm

Hemobilia is a potentially life-threatening clinical issue, the etiology of which iatrogenesis is playing increasingly more prominent role. Nowadays the most frequent etiology of hemobilia has shifted toward iatrogenesis owing to increasingly more frequent performance of liver procedures, either open or minimally invasive. Here we report a rare case of recurrent hemobilia after transarterial embolization. A man, aged 57 years, presented with Quincke's triad after cholecystectomy. Computed tomography imaging revealed a pseudoaneurysm of the right hepatic artery. Transarterial embolization failed, and hemobilia recurred. The patient underwent open ligation of the right hepatic artery. Transarterial embolization is a definitive treatment of hemobilia due to vascular issues. The choice of embolizing agent is crucial in transarterial embolization.

Iatrogenic, blunt, and penetrating trauma to the biliary tract

Iatrogenic and traumatic bile leaks are uncommon. However, given the overall increase in number of hepatobiliary surgeries and the paradigm shift toward nonoperative management of patients with liver trauma, they have become more prevalent in recent years. Imaging is essential to establishing early diagnosis and guiding treatment as the clinical signs and symptoms of bile leaks are nonspecific, and a delay in recognition of bile leaks portends a high morbidity and mortality rate. Findings suspicious for a bile leak at computed tomography or ultrasonography include free or contained peri- or intrahepatic low density fluid in the setting of recent trauma or hepatobiliary surgery. Hepatobiliary scintigraphy and magnetic resonance cholangiopancreatography (MRCP) with hepatobiliary contrast agents can be used to detect active or contained bile leak. MRCP with hepatobiliary contrast agents has the unique ability to reveal the exact location of bile leak, which often governs whether endoscopic management or surgical management is warranted. Percutaneous transhepatic cholangiography and fluoroscopy via an indwelling catheter that is placed either percutaneously or surgically are useful modalities to guide percutaneous transhepatic biliary drain placement which can provide biliary drainage and/or diversion in the setting of traumatic biliary injury. Surgical treatment of a bile duct injury with Roux-en-Y hepaticojejunostomy is warranted if definitive treatment cannot be accomplished through percutaneous or endoscopic means.

Abrupt occlusion of right gastroepiploic artery as an angiographic evidence of gastrointestinal hemorrhage

Angiography plays an important role in both diagnosis and treatment of gastrointestinal (GI) bleeding; however, the sensitivity is low for diagnosis. We report a case of a 38-year-old woman who presented with recurrent upper GI bleeding following central pancreatectomy. Multiple selective arteriograms failed to reveal any active bleeding or other common signs of bleeding. There was an abrupt occlusion of the right gastroepiploic artery initially interpreted to be a surgical ligation. Upon direct superselective injection near the occlusion, an area of frank contrast extravasation was demonstrated immediately beyond the occlusion. The underlying vessel was embolized with n-butyl cyanoacrylate without recurrent bleeding up to 3-month follow-up.