P2200 - Acute GI Bleeding Secondary to Rare Presentation of Arterio-biliary Fistula

Shahd Duzdar, MD¹, Mark Gromski, MD^2
1Indiana University, Indianapolis, IN; ²Indiana University School of Medicine, Indianapolis, IN

Introduction: Arterio-biliary fistulas are rarely encountered in the medical setting. We describe a case of a transpapillary bleed secondary to arterio-biliary fistula repaired with endovascular stenting.

Case Description/Methods: A 67-year-old man was admitted due to melena. He has a remote history of metastatic colon cancer, status post partial right and full left hepatectomy and a hepatic arterial chemotherapy infusion pump. Clinical course was complicated by elevated liver tests and cholangitis. Initial ERCP demonstrated common hepatic duct stricture, treated with biliary stent placement. Given ongoing jaundice, an IR-guided percutaneous biliary drain (internal/external) was placed.









He presented with melena and bleeding around his percutaneous biliary drain site. Labs showed a hemoglobin drop from 9.9 to 7.9, elevated liver tests: ALP 314, ALT 121, AST 205, and total bilirubin of 15.9. Patient subsequently developed hypotension which was responsive to fluids. Contrast-enhanced CT did not show any evidence of pseudoaneurysm, traumatic AV fistula or active bleeding. ERCP was performed, with removal of a biliary cast at the major papilla and immediate transpapillary flow of pulsatile blood. An extraction balloon was used to tamponade the area and patient was transferred to the IR suite for angiography. Acute bleeding was shown from the main right hepatic artery through an arterio-biliary fistula. Placement of a Viabahn endovascular stent led to cessation of hemorrhage and hemodynamic stabilization.






Discussion: Arterio-biliary fistula is an uncommon cause of hemobilia, with few cases described in the literature. The most common cause is iatrogenic¹. Our patient had extensive manipulation to his biliary tree including surgery, ERCP with prior stenting and a recently placed percutaneous biliary drain. It is suspected that iatrogenic manipulation was the cause of the fistula in this patient, with the hepatic artery infusion catheter and percutaneous biliary drain likely creating an area of pressure and eventual fistulization. ERCP in this case showed evidence of an active bleed with emergent angiography confirming the diagnosis. Treatment for hemobilia involves mainly endoscopic treatment or vascular embolization, with endovascular treatment rarely reported¹. Our case demonstrates successful life-saving management of hemobilia with endovascular stenting.



Zhornitskiy et al. (2019). Hemobilia: Historical overview, clinical update, and current practices. In Liver International (V 39, I 8). Blackwell Publishing Ltd.




Figure: Acute pulsatile arterial bleed from the major duodenal papilla


Disclosures:
Shahd Duzdar indicated no relevant financial relationships.
Mark Gromski indicated no relevant financial relationships.


Shahd Duzdar, MD¹, Mark Gromski, MD². P2200 - Acute GI Bleeding Secondary to Rare Presentation of Arterio-biliary Fistula, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.