Vascular anomaly as a cause of late bleeding after endoscopic retrograde cholangiopancreatography: A case report

Abstract

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding is a serious complication, and related case reports have described various bleeding events following ERCP, including injury to the right gastroepiploic artery, bleeding from biliary varices, retroperitoneal hematoma in liver transplant recipients and subcapsular liver hematoma after ERCP.

CASE SUMMARY

We present a case of a 55-year-old male patient who developed post-ERCP hemorrhage one month after undergoing ERCP, endoscopic sphincterotomy, and bile duct stone removal for acute biliary pancreatitis. The patient presented with upper abdominal pain and melena, and imaging studies revealed high-density shadows in the intrahepatic bile duct, gallbladder, and lower segment of the common bile duct, suggestive of bleeding. Emergency interventional embolization was performed, and subsequent endoscopic and interventional therapies were implemented to control the bleeding. The patient’s hemoglobin levels gradually improved, and biliary indicators normalized.

CONCLUSION

Post-ERCP bleeding can result from various etiologies, and the rupture of variant vessels is a noteworthy topic warranting further exploration.

Key Words: Post-endoscopic retrograde cholangiopancreatography hemorrhage; Endoscopic sphincterotomy; Interventional embolization; Vascular variation; Acute biliary pancreatitis; Case report

Core Tip: This case report describes a 55-year-old male patient who experienced post-endoscopic retrograde cholangiopancreatography (ERCP) hemorrhage one month after undergoing ERCP, endoscopic sphincterotomy, and bile duct stone removal for acute biliary pancreatitis. The patient presented with upper abdominal pain and melena, and imaging studies revealed high-density shadows suggestive of bleeding. Emergency interventional embolization and subsequent endoscopic and interventional therapies were successful in controlling the bleeding, highlighting the importance of recognizing and managing various etiologies of post-ERCP bleeding, including the rupture of variant vessels.

INTRODUCTION

We present a case of a 55-year-old male patient who developed post-endoscopic retrograde cholangiopancreatography (ERCP) hemorrhage one month after undergoing ERCP, endoscopic sphincterotomy (EST), and bile duct stone removal for acute biliary pancreatitis. The patient presented with upper abdominal pain and melena, and imaging studies revealed high-density shadows in the intrahepatic bile duct, gallbladder, and lower segment of the common bile duct, suggestive of bleeding. Emergency interventional embolization was performed, and subsequent endoscopic and interventional therapies were implemented to control the bleeding. The patient’s hemoglobin levels gradually improved, and biliary indicators normalized. Similarly, other related case reports have described various bleeding events following ERCP, including injury to the right gastroepiploic artery[1], bleeding from biliary varices[2], retroperitoneal hematoma in liver transplant recipients[3] and subcapsular liver hematoma after ERCP (Table 1)[4]. Overall, this case highlights the challenges of managing post-ERCP hemorrhage, particularly in the context of vascular variations, and underscores the importance of a multidisciplinary approach to treatment.

Table 1 Case reports of vascular anomaly.

Ref.	Year	Outcome	Management
Risher and Smith[1]	1990	Injury the gastroepiploic artery	Ligate the right gastroepiploic artery
Tighe and Jacobson[2]	1996	Bile duct varices	Ligate the bile duct varices
Cárdenas et al[3]	2008	Subcapsular hepatic hematoma	Place the biliary plastic stent
Zizzo et al[4]	2015	Subcapsular hepatic hematoma	Embolization the right hepatic artery

CASE PRESENTATION

Chief complaints

A 55-year-old male patient was admitted to an external hospital for “acute biliary pancreatitis” and underwent ERCP, EST, and bile duct stone extraction. One month of post-procedure, the patient presented with sudden upper abdominal pain and melena, leading to his admission to our hospital. Emergency whole-abdomen computed tomography (CT) revealed high-density shadows in the intrahepatic bile ducts, gallbladder, and lower common bile duct, suggesting possible hemorrhage.

History of present illness

The patient presented with abdominal pain and hematochezia two days ago without any apparent precipitating factors. There were no accompanying symptoms such as nausea, vomiting, dizziness, headache, chest tightness, or palpitations. The patient received symptomatic treatment at a local hospital, but the details of the treatment are unclear, and the symptoms did not improve. The patient was referred to our hospital for further evaluation and management and was admitted to our department with a diagnosis of gastrointestinal bleeding.

History of past illness

On October 18, 2023, the patient was diagnosed with acute biliary pancreatitis and underwent “ERCP + EST + bile duct stone extraction” at an outside hospital. The specific details of the procedure are not available.

Personal and family history

The patient has no significant past medical history and denies a history of hypertension or diabetes. The patient also denies a history of infectious diseases such as hepatitis B or tuberculosis. There is no family history of genetic disorders.

Physical examination

There was mild tenderness in the right upper quadrant without rebound tenderness. Bowel sounds were hyperactive.

Laboratory examinations

Blood tests showed: (1) Hemoglobin: 51.0 g/L (normal range: 130.0-175.0 g/L); (2) Total bilirubin: 136.3 μmol/L; (3) Direct bilirubin: 129.1 μmol/L; and (4) Transaminase: 91 U/L.

Imaging examinations

Emergency whole-abdomen CT revealed high-density shadows in the intrahepatic bile ducts, gallbladder, and lower common bile duct, suggesting possible hemorrhage.

FINAL DIAGNOSIS

Hemorrhage from the right hepatic artery (Figures 1 and 2).

Figure 1 Bleeding part. A: Bleeding from a small branch of the gastroduodenal artery; B: Bleeding from a small arterial branch of the gastroduodenal artery supplying the left lobe of the liver; C: Bleeding from a small arterial branch of the right hepatic artery anastomosing with the left hepatic artery.

Figure 2  The entire process of endoscopic hemostasis.

TREATMENT

Embolic occlusion of a small branch of the right hepatic artery was performed (Figures 3 and 4).

Figure 3 Disappearance of the bleeding point. A: After interventional embolization, the bleeding points in the small branches of the gastroduodenal artery were no longer detectable; B: After interventional embolization, the bleeding points in the small arterial branch of the gastroduodenal artery supplying the left lobe of the liver were no longer detectable; C: After interventional embolization, the bleeding points in the small arterial branch of the right hepatic artery anastomosing with the left hepatic artery were no longer detectable.

Figure 4  Management flowchart for delayed post-endoscopic retrograde cholangiopancreatography bleeding.

OUTCOME AND FOLLOW-UP

The patient’s hemoglobin levels showed an upward trend, and his biliary indices gradually returned to normal. His abdominal pain improved, and he recovered well.

DISCUSSION

In this case, the patient experienced significant gastrointestinal bleeding one month of post-ERCP, which was successfully managed through three interventional treatments and one endoscopic hemostasis. The most likely cause of the bleeding from the variant vessel was related to the surgical procedure and local inflammatory response.

CONCLUSION

Accurate identification of the cause of post-ERCP hemorrhage is essential for precise treatment. In decision-making, it is crucial to consider multiple potential causes of bleeding rather than adhering to a single hypothesis.