1269 Massive Life-Threatening Hemobilia Managed Successfully at ERCP: The Importance of Teamwork and Appropriate Interventions in a Catastrophic Situation!

Abstract

INTRODUCTION: Clinically significant bleeding at ERCP is encountered in 0.1% to 2% cases. Hemobilia is relatively uncommon and usually mild. Here we present a case of successful management of massive life-threatening hemobilia during ERCP. CASE DESCRIPTION/METHODS: A 79-year male with T2N0 pancreatic tail adenocarcinoma s/p distal pancreatectomy in 2007, cirrhosis and portal hypertension developed obstructive jaundice due to recurrent pancreatic head malignancy 11 years later. ERCP with placement of an uncovered 10 mm × 40 mm SEMS was performed. Recurrent cholangitis 4 months later required repeat ERCP, revealing extension of stricture to the CHD. A 10 F × 12 cm plastic biliary stent was placed through the metal stent into the right hepatic duct. At repeat ERCP six weeks later, the plastic biliary stent was removed easily with snare. Approximately one minute later, massive hemobilia ensued with complete occlusion of endoscopic visual field. Due to volume and rapidity of bleeding, it was suspected that bleeding was from tumor erosion of intraductal varices. Approximately 1.2 liters of blood was lost in less than 5 minutes resulting in hemodynamic instability. During this time, the following decisions and events were put into motion: 1. Anesthesia attending took charge of patient's hemodynamics, central venous access, pressor support and PRBC transfusion, 2. Charge nurse alerted ICU team, sent additional nursing and tech resources to room, 3. The endoscopist focused on clearing the duodenal luminal field with aim to re-establish biliary access, however this was very difficult due to amount of blood/clot in the visual field, 4. Two additional endoscopists helped re-position patient to left lateral position, enabling visualization & biliary access, 5. Per consensus, placement of a fully covered SEMS was the only endoscopic option that could achieve hemostasis, 6. A10 mm × 60 mm fully covered SEMS was placed into the CBD/CHD with tamponade of hemobilia and restoration of biliary drainage, 7. Patient was transferred to PACU, extubated, recovered uneventfully and discharged home × 48 hrs. DISCUSSION: Massive, life threatening hemobilia can occur from friable tumors/intraductal varices even with minimal manipulation. Teamwork and correct medical decision making are critical to a successful outcome during such catastrophic endoscopic events. Placement of a fully covered metal biliary stent served a dual purpose of tamponading hemobilia and relieving biliary obstruction in this case.