A case of successful placement of a fully covered metallic stent for hemobilia secondary to hepatocellular carcinoma with bile duct invasion

Transarterial Therapy for Hepatocellular Carcinoma Invading the Bile Duct

Hepatocellular carcinoma invading the bile duct (bile duct tumor thrombus) is an unfavorable condition. Although overall survival following surgical resection among patients with hepatocellular carcinoma with bile duct tumor thrombus is significantly better than that among those treated with transarterial chemoembolization or chemotherapy, surgical resection can be indicated for selected patients. Additionally, systemic therapy is indicated only for patients with Child-Pugh class A. Therefore, transarterial therapy plays an essential role in the treatment of bile duct tumor thrombus. Transarterial chemoembolization with iodized oil and gelatin sponge particles is an established first-line transarterial treatment that can necrotize most bile duct tumor thrombi. However, we should pay attention to symptoms caused by intraductal hemorrhage during transarterial chemoembolization and the sloughing of necrotized bile duct tumor thrombi.

Hemostasis with Metallic Stent for Multiple Metastatic Pancreatic Tumors Complicated with Hemobilia

Introduction

Hemobilia, which refers to bleeding from the bile duct, is rare and difficult to treat. We report a case of successful hemostasis of a pancreatic tumor complicated by hemobilia.

Case Presentation

A 76-year-old man was referred to our hospital with a pancreatic head tumor. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography-FNA were performed, and the patient was diagnosed with pancreatic metastasis of renal cell carcinoma. After discharge, the patient noted worsening jaundice and progressive anemia and was readmitted. ERCP reveals active bleeding from the duodenal papillae. The patient was placed on a fully covered metallic stent and discharged after confirming hemostasis.

Conclusion

Renal cell carcinoma is a tumor with abundant blood flow. If hemobilia occurs, bleeding from pancreatic metastatic tumors should be considered. Additionally, hemostasis using a fully covered metallic stent is useful for treating hemobilia in tumors.

Endoscopic Management of Tumor Bleeding: Techniques and Strategies

Endoscopic management of gastrointestinal (GI) tumor-related bleeding is challenging for many reasons including high rebleeding rates, poor tissue response to endoscopic therapies, altered wound healing and underlying coagulopathy. However, endoscopic treatment may help reduce transfusion requirements, avoid surgery, and provide a temporary bridge to oncologic therapy. This article explores various endoscopic techniques in managing tumor bleeding from more traditional approaches of using thermal or mechanical therapy with injection therapy to newer topical agents.

Hemostasis using a covered self‐expandable metal stent for pseudoaneurysm bleeding from the perihilar bile duct

Although there are many reports of hemostasis with covered self‐expandable metal stent (CSEMS) for bleeding from the papilla of Vater and the intrapapillary and distal bile duct, there are rare reports of its use for hemostasis in the perihilar bile duct. We report the case of a patient undergoing supportive care for perihilar cholangiocarcinoma with acute cholecystitis after side‐by‐side placement of uncovered SEMS for perihilar bile duct obstruction. Percutaneous transhepatic gallbladder aspiration was performed upon admission, and hematemesis occurred the next day. Since computed tomography scanning showed a pseudoaneurysm in the right uncovered SEMS, hemostasis by interventional radiology (IVR) was performed thrice for massive bleeding; however, hemostasis could not be achieved. When endoscopic retrograde cholangiopancreatography was performed for scrutiny and treatment of melena and increased hepatobiliary enzyme, the endoscopic visual field could not be secured by bleeding, and changes in hemodynamics were observed; thus, IVR was required, but it was difficult to perform. Since bleeding from the right bile duct was expected, hemostasis was performed using CSEMS. This is the first report of hemostasis performed by placing a covered SEMS for bleeding from a pseudoaneurysm of the intrahepatic bile duct.

A case of hemobilia caused by pancreatic metastasis of renal cell carcinoma treated with a covered metallic stent

We present the case of an 86-year-old man who had undergone left nephrectomy for renal cell carcinoma (clear cell carcinoma) 22 years ago. He visited the emergency department complaining of right hypochondrial pain and fever. He was eventually diagnosed with acute cholangitis. Abdominal contrast-enhanced computed tomography showed multiple tumors in the pancreas. The tumor in the pancreatic head obstructed the distal bile duct. Endoscopic retrograde cholangiopancreatography detected bloody bile juice flowing from the papilla of Vater. Therefore, he was diagnosed with hemobilia. Cholangiography showed extrinsic compression of the distal bile duct; a 6 Fr endoscopic nasobiliary drainage tube was placed. Endoscopic ultrasound showed that the pancreas contained multiple well-defined hypoechoic masses. Endoscopic ultrasound-guided fine-needle aspiration was performed using a 22 G needle. Pathological examination revealed clear cell carcinoma, and the final diagnosis was pancreatic metastasis of renal cell carcinoma (RCC) causing hemobilia. A partially covered metallic stent was placed in the distal bile duct. Consequently, hemobilia and cholangitis were resolved.

The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding

Bilio-duodenal bleeding, such as post-endoscopic sphincterotomy (EST) bleeding, common bile duct (CBD) bleeding after endoscopic retrograde cholangiopancreatography (ERCP), and duodenal bleeding due to malignant tumour invasion, can sometimes become severe. Six cases of refractory bilio-duodenal bleeding were stanched via covered self-expandable metallic stent (CSEMS) insertion, even though three of the patients had a history of gastrectomy. The dumbbell-shaped CSEMS was useful for managing post-EST bleeding. Additional duodenal CSEMS insertion was useful for the patient who had previously undergone uncovered SEMS insertion, and no migration of the CSEMS was observed. CSEMS insertion was useful for treating refractory bilio-duodenal haemorrhaging.

Triple Covered Metal Stent Deployment Using Side-by-Side Technique for Hemobilia due to Hepatocellular Carcinoma (with Video)

A hepatocellular carcinoma (HCC) rarely expands into the biliary tract. In this situation, because of its hypervascular nature, cholangitis or hemobilia may sometimes occur. Surgery is one of the options in this situation. However, patients with HCC and bile duct invasion are sometimes in a poor general condition, as in the case presented in this report. For such patients, surgical treatment may need to be invasive. Thus, here we report technical tips for triple covered metal stent deployment using side-by-side technique for hemobilia due to HCC. After guidewire deployments at the left, anterior, and posterior bile ducts, 6-mm covered self-expandable metal stents were placed at each bile duct. This may be useful for high-grade hepatic hilar obstruction due to HCC because drainage and hemostasis effects are obtained.

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.

Hemobilia Leading to a Diagnosis of Hepatocellular Carcinoma

Hemobilia from hepatocellular carcinoma (HCC) is rare and is usually noted in established cases of HCC after invasive procedures. Hemobilia can present with serious complications including acute pancreatitis and cholangitis. We describe an unusual case of hemobilia causing obstructive jaundice with suspected cholangitis and acute pancreatitis with subsequent workup revealing HCC.

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.

Hemobilia: An Uncommon But Notable Cause of Upper Gastrointestinal Bleeding

GOAL AND BACKGROUND

A literature review to improve practitioners' knowledge and performance concerning the epidemiology, diagnosis, and management of hemobilia.

STUDY

A search of Pubmed, Google Scholar, and Medline was conducted using the keyword hemobilia and relevant articles were reviewed and analyzed. The findings pertaining to hemobilia etiology, investigation, and management techniques were considered and organized by clinicians practiced in hemobilia.

RESULTS

The majority of current hemobilia cases have an iatrogenic cause from either bile duct or liver manipulation. Blunt trauma is also a significant cause of hemobilia. The classic triad presentation of right upper quadrant pain, jaundice, and upper gastrointestinal bleeding is rarely seen. Computed tomography and magnetic resonance imaging are the preferred diagnostic modalities, and the preferred therapeutic management includes interventional radiology and endoscopic retrograde cholangiopancreatography. Surgery is rarely a therapeutic option.

CONCLUSIONS

With advances in computed tomography and magnetic resonance imaging technology, diagnosis with these less invasive investigations are the favored option. However, traditional catheter angiography is still the gold standard. The management of significant hemobilia is still centered on arterial embolization, but arterial and biliary stents have become accepted alternative therapies.

Management of bleeding liver tumors

Liver tumors bleed rarely; management has changed radically during the last 20years, advancing from emergency surgery with poor results to multidisciplinary management. The first steps are the diagnosis and control of bleeding. Abdominopelvic CT scan should be performed as soon as patient hemodynamics allow. When active bleeding is visualized, arterial embolization, targeted as selectively as possible, is preferable to surgery, which should be reserved for severe hemodynamic instability or failure of interventional radiology. When surgery is unavoidable, abbreviated laparotomy (damage control) with perihepatic packing is recommended. The second step is determination of the etiology and treatment of the underlying tumor. Adenoma and hepatocellular carcinoma (HCC) are the two most frequently encountered tumors in this context. Liver MRI after control of the bleeding episode generally leads to the diagnosis although sometimes the analysis can be difficult because of the hematoma. Prompt resection is indicated for HCC, atypical adenoma or lesions at risk for degeneration to hepatocellular carcinoma. For adenoma with no suspicion of malignancy, it is best to wait for the hematoma to resorb completely before undertaking appropriate therapy.

Evaluation of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma

AIM: To review the usefulness of endoscopic biliary stenting for obstructive jaundice caused by hepatocellular carcinoma and identify problems that may need to be addressed.

METHODS: The study population consisted of 36 patients with obstructive jaundice caused by hepatocellular carcinoma (HCC) who underwent endoscopic biliary stenting (EBS) as the initial drainage procedure at our hospital. The EBS technical success rate and drainage success rate were assessed. Drainage was considered effective when the serum total bilirubin level decreased by 50% or more following the procedure compared to the pre-drainage value. Survival time after the procedure and patient background characteristics were assessed comparatively between the successful drainage group (group A) and the non-successful drainage group (group B). The EBS stent patency duration in the successful drainage group (group A) was also assessed.

RESULTS: The technical success rate was 100% for both the initial endoscopic nasobiliary drainage and EBS in all patients. Single stenting was placed in 21 patients and multiple stenting in the remaining 15 patients. The drainage successful rate was 75% and the median interval to successful drainage was 40 d (2-295 d). The median survival time was 150 d in group A and 22 d in group B, with the difference between the two groups being statistically significant (P < 0.0001). There were no statistically significant differences between the two groups with respect to patient background characteristics, background liver condition, or tumor factors; on the other hand, the two groups showed statistically significant differences in patients without a history of hepatectomy (P = 0.009) and those that received multiple stenting (P = 0.036). The median duration of stent patency was 43 d in group A (2-757 d). No early complications related to the EBS technique were encountered. Late complications occurred in 13 patients (36.1%), including stent occlusion in 7, infection in 3, and distal migration in 3.

CONCLUSION: EBS is recommended as the initial drainage procedure for obstructive jaundice caused by HCC, as it appears to contribute to prolongation of survival time.