A case of hemobilia with hemorrhagic shock; successfully performed emergency ERCP to identify bleeding point by stone retrieval balloon and to achieve hemostasis by placing fully-covered metal stent

Abstract

A 75-year-old man with unresectable locally advanced pancreatic body cancer underwent chemotherapy after biliary drainage with uncoverd self-expandable metal stent (SEMS). The patient was referred to our department due to hematemesis. Upper gastrointestinal endoscopy could not find out a bleeding point. Contrast-enhanced CT showed no aneurysm, but a suspicious finding of extensive blood clots from the right hepatic duct to the common bile duct. Because laboratory data showed jaundice with inflammation suspected of cholangitis, emergency ERCP was intended for biliary drainage. However, when ERCP was performed, we saw a large amount of fresh blood was overflowing from the bile duct, then we decided to use a stone retrieval balloon to identify the bleeding point. After repeated dilatation while moving the balloon from the distal common bile duct to the both hepatic ducts, the bleeding from the bile duct stopped even after dilatation in the right hepatic duct, and we assumed that the bleeding was coming from the same area. A fully-covered SEMS was placed from the common bile duct to the right anterior segment branch, and the bleeding was continuously stopped. This procedure is a useful novel method to detect bleeding point of hemobilia.