Hemobilia Post Intrabiliary Photodynamic Therapy (PDT) for Cholangiocarcinoma

Abstract

Purpose: Case 1: A 61 years old lady presented with jaundice and was diagnosed with an unresectable Klatskin tumor. She underwent CBD stenting and 2 cycles of intraductal PDT. She presented 6 weeks after her second cycle with severe hematemesis. An EGD revealed hemobilia (Fig. 1). Angiography showed pseudoaneurysms from both the right hepatic artery and the accessory right hepatic artery (Fig. 2). These were embolized and the patient's bleeding stopped. Case 2: A 53 years old male with ulcerative colitis and PSC was found to have a hilar, non resectable cholangiocarcinoma. He underwent a transcutaneous cholangiogram and biliary drain placement. An abdominal MRI done for staging showed a large left hepatic artery pseudoaneurysm which was successfully embolized. Two weeks later he underwent transcutaneous PDT. He presented 48 hours later with massive hemobilia thrpugh his drain. Angiography revealed bleeding from an aneurysm around the previous embolization site of the left hepatic artery as well as from new collaterals from the right hepatic artery. This was successfully injected with Ivalon particles. Discussion: We presented two cases of hemobilia from hepatic artery pseudoaneurysms following intrabiliary PDT. When reviewing the literature for reported complications of intrabiliary PDT we found very few cases of hemobilia. It is unclear if bleeding is the result of the radiation from PDT itself or whether other mechanisms are involved. We think that patients with known or suspected hepatic artery pseudoaneurysms or aneurysms should undergo treatment for these by an expert interventional radiologist before proceeding with PDT. We cannot recommend routine angiography prior to PDT in all patients at this time.[figure1][figure2]FigureFigure