Clin J Gastroenterol (2013) 6:80–83 DOI 10.1007/s12328-012-0354-x
CASE REPORT
Hemorrhage from bile duct varices treated with fully covered expandable metallic stent placement in pancreatic carcinoma Chisato Ueda • Masataka Kikuyama Tatsuki Ueda • Takafumi Kurokami
•
Received: 16 August 2012 / Accepted: 16 December 2012 / Published online: 5 January 2013 Ó Springer Japan 2013
Abstract A 64-year-old woman with unresectable pancreatic body carcinoma was admitted with epigastralgia with a sudden onset 6 h earlier. She had received chemotherapy for her cancer for 2 months. Physical examination showed mild anemia. Contrast-enhanced computed tomography showed dilated vessels in the bile duct walls connecting with dilated and tortuous vessels around the extrahepatic bile duct and portal vein obstruction due to invasion by a pancreatic body tumor. Endoscopic examination showed transpapillary hemorrhage suggesting bile duct hemorrhage. On endoscopic retrograde cholangiopancreatography, the lower bile duct was filled with a mass and the middle bile duct had filling defects with compression of the wall. To stop the bleeding, we placed a fully covered expandable metallic stent (EMS) at the middle to lower portion of the bile duct, and the hemorrhage stopped. Bile duct hemorrhage is not a common disorder. This report shows bile duct hemorrhage from bile duct varices can occur in patients with pancreatic carcinoma with portal obstruction and that fully covered EMS placement can stop the hemorrhage. Keywords Expandable metallic stent Bile duct hemorrhage Pancreatic cancer
Introduction Portal vein obstruction causes cavernous transformation and in rare instances bile duct varices [1], which can lead to C. Ueda M. Kikuyama (&) T. Ueda T. Kurokami Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-ando, Aoiku, Shizuoka, Shizuoka 420-8527, Japan e-mail: [email protected]
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bile duct hemorrhage from invasive biliary tract procedures [2]. Bile duct hemorrhage can be treated with placement of an expandable metallic stent (EMS) [3], but reports about this treatment are rare. Here we report a case of pancreatic carcinoma and spontaneous hemorrhage from bile duct varices that we treated with fully covered EMS placement.
Case report A 64-year-old woman with unresectable pancreatic body carcinoma was admitted with epigastralgia with a sudden onset 6 h earlier. She had received chemotherapy for her cancer for 2 months. Physical examination showed mild anemia. Blood laboratory evaluations revealed decreased hemoglobin (Hb; 9.0 g/dL) with elevated hepatobiliary enzymes (AST 1295 U/L, ALT 969 U/L, ALP 679 U/L, cGTP 639 U/L, and total bilirubin 2.4 mg/dL). Plain computed tomography (CT) of the upper abdomen showed highly dense masses in the extrahepatic bile duct (Fig. 1). Contrast-enhanced CT performed 2 months earlier had showed dilated vessels in the bile duct walls connecting with dilated and tortuous vessels around the extrahepatic bile duct and portal vein obstruction due to invasion by a pancreatic body tumor (Fig. 2). The finding of vessel abnormalities had revealed bile duct varices and cavernous transformation. Endoscopic examination showed transpapillary hemorrhage suggesting bile duct hemorrhage (Fig. 3). On endoscopic retrograde cholangiopancreatography (ERCP), the lower bile duct with a diameter of 8 mm was filled with a mass and the middle bile duct had filling defects with compression of the wall (Fig. 4). Bile duct hemorrhage due to bile duct varices was considered to be
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possible. To stop the bleeding, we placed a fully covered EMS (10 9 80 mm, WallflexTM Biliary RX; Boston Scientific) at the middle to lower portion of the bile duct (Fig. 5) and the hemorrhage stopped. The day after the endoscopic treatment, the symptoms and the abnormal blood laboratory measurements showed improvement and the Hb level had not worsened. During a 4-month follow-up after the procedure, the symptoms have not recurred and the blood count and liver enzymes have recovered to the normal range.
Discussion
Fig. 1 Plain abdominal CT showing highly dense masses in the lower extrahepatic bile duct (arrow)
Bile duct hemorrhage is not a common disorder and is seen in patients with gallstones, gallbladder carcinomas, biliary pseudoaneurysms, or tendency for hemorrhage. Bile duct varices also cause bile duct hemorrhage.
Fig. 2 Contrast-enhanced CT showing dilated vessels in the bile duct walls (a, b; arrow) connecting with dilated and tortuous vessels around the extrahepatic bile duct (c; arrow) and portal vein obstruction due to invasion by a pancreatic body tumor (d; arrowhead)
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Fig. 3 Endoscopic examination showing transpapillary hemorrhage
Fig. 4 ERCP showing a mass in the lower bile duct (a; arrow) and filling defects with compression of the wall at the middle bile duct (b; arrow head)
Bile duct varices were first described by using ERCP and correlating it with angiography in a patient with pancreatic carcinoma in 1982 [4], but have been rarely reported [1, 2, 4–8]. Varices of the hepatoduodenal ligament and the porta hepatis are common sequelae of chronic portal vein thrombosis known as cavernous transformation. Bile duct varices are dilated vessels within the bile duct wall connecting with the cavernous transformation [2]. The diagnosis of bile duct varices depends on the findings of ERCP and CT. Filling defects of the bile duct can be seen on cholangiography. Compression by dilated vessels in the bile duct wall is responsible for these findings, which should be distinguished from those by bile duct tumors [6]. CT helps to distinguish these two conditions by showing the dilated vessels in the bile duct connected with cavernous transformation [2]. Findings of irregular bile duct strictures are called a pseudo-choriocarcinoma sign [6]. Cholangioscopic examination techniques have advanced and bile duct varices can now be recognized with cholangioscopy. However, these rare conditions become clinically important when they cause bile duct hemorrhage. Cholangioscopic examination is not considered to be useful for bile duct varices in patients with portal vein obstruction. Once hemorrhage occurs, there is no time to perform cholangioscopic examination because endoscopic papillotomy with introduction of a cholangioscope during hemorrhage is risky given the patient’s poor condition, and the bile duct lumen filled with blood cannot be observed due to its small diameter even if saline is injected through its working channel. We recognized the vessel abnormalities in the present case with contrast-enhanced CT of the upper abdomen,
which originated from the upper portion of the superior mesenteric vein, passed through the head of the pancreas, and continued into the portal vein at the porta hepatis forming cavernous transformation and connecting with dilated vessels in the bile duct wall. Filling defects of the middle bile duct on cholangiography were considered to be compressions by the dilated vessels called bile duct varices [8], causing bile duct hemorrhage. No other abnormalities were observed on contrast-enhanced CT that could potentially cause bile duct hemorrhage. We placed a fully covered EMS to put pressure upon the bile duct wall to stop the hemorrhage, and we achieved our goal. In this setting, a fully covered EMS is more favorable than a non-covered EMS, because varices could protrude through the stent interstices and cause hemorrhage if a noncovered EMS was used [1]. Furthermore, the diameter of an EMS should be larger than that of a bile duct, because of the necessity to oppress the bile duct. Fully covered EMS placement to stop hemorrhage from the bile duct in a case of post-endoscopic sphincterotomy (EST) was previously described [3], but there is no report using this procedure for bile duct varices. Hemorrhage from varices is commonly treated with endoscopic injection sclerotherapy when varices are located at the esophagus, stomach, duodenum, or the cholangio-jejunal anastomosis [9]. However, sclerotherapy with cholangioscopy under hemorrhage is impossible because cholangioscopic examination is hard to perform for reasons described above. On the other hand, EMS placement was reported to treat hemorrhage from esophageal varices [10]. Endoscopic injection sclerotherapy and endoscopic variceal ligation are accepted treatments for the hemorrhage. EMS placement is
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Fig. 5 A fully covered EMS was placed at the middle to lower portion of the bile duct (a) with the lower end in the duodenal cavity (b)
an alternative treatment. EMS placed at the esophagus is easy to migrate due to esophageal peristalsis, and EMS placement does not have a role to eradicate esophageal varices or to prevent recurrence of hemorrhage. Transjugular intrahepatic portosystemic shunt placement as interventional radiology (IVR) was reported to be effective in treating hemorrhage from bile duct varices [11]. Generally, in patients with gastrointestinal hemorrhage, endoscopic hemostatic procedures should be the first-line treatment to stop bleeding, and IVR remains to be selected when endoscopic hemostasis fails because preparation of IVR takes time and cannot always be performed in all hospital. In patients with bile duct hemorrhage, endoscopic treatment should be prior to IVR for the same reasons, i.e., if the hemorrhage could be treated with EMS placement or balloon compression through the duodenal papilla. This report shows bile duct hemorrhage from bile duct varices can occur in patients with pancreatic carcinoma with portal obstruction and fully covered EMS placement can stop the hemorrhage. Conflict of interest of interest.
The authors declare that they have no conflict
References
2. Chow L, Jeffrey Jr RB. Intramural varices of the bile duct: an unusual pattern of cavernous transformation of the portal vein. Am J Roentgenol. 1999;173:1255–6. 3. Itoi T, Yasuda I, Doi S, Mukai T, Kurihara T, Sofuni A. Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding. Endoscopy. 2011;43:369–72. 4. Williams SM, Burnett DA, Mazer MJ. Radiographic demonstration of common bile duct varices. Gastrointest Radiol. 1982;7:69–70. 5. Song MH, Kim MH, Lee SK, Lee SS, Seo DW. Bile duct varices. Gastrointest Endosc. 2004;59:869–70. 6. Bayraktar Y, Balkanci F, Kayhan B, Arslan S, Koseoglu T, Ozdemir A, et al. Bile duct varices or ‘‘pseudo-cholangiocarcinoma sign’’ in portal hypertension due to cavernous transformation of the portal vein. Am J Gastroenterol. 1992;87:1801–6. 7. Ikegami T, Matsuzaki Y, Saito Y, Nishi M, Tanaka N, Osuga T, et al. Endoscopic diagnosis of common bile duct varices by percutaneous trans-hepatic choledochoscopy: differential diagnosis from bile duct carcinoma. Gastrointest Endosc. 1994;40: 637–40. 8. Tighe M, Jacobson I. Bleeding from bile duct varices: an unexpected hazard during therapeutic ERCP. Gastrointest Endosc. 1996;43:250–2. 9. Ito T, Segawa T, Kanematsu T. Successful endoscopic injection sclerotherapy for bleeding from bile duct varices. Surg Today. 1997;27:174–6. 10. Hubmann R, Bodlaj G, Czompo M, et al. The use of selfexpanding metal stent to treat acute esophageal variceal bleeding. Endoscopy. 2006;38:896–901. 11. Gorgul A, Kayhan B, Dogan I, Unal S. Disappearance of the pseudo-cholangiocarcinoma sign after TIPPS. Am J Gastroenterol. 1996;91:150–3.
1. Cvetkovski B, Kurtz RC. Hemobilia in advanced pancreatic cancer with portal vain obstruction and a metal endobiliary stent: a case report. Gastrointest Endosc. 1999;50:420–2.
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CASE REPORT
Hemorrhage from bile duct varices treated with fully covered expandable metallic stent placement in pancreatic carcinoma Chisato Ueda • Masataka Kikuyama Tatsuki Ueda • Takafumi Kurokami
•
Received: 16 August 2012 / Accepted: 16 December 2012 / Published online: 5 January 2013 Ó Springer Japan 2013
Abstract A 64-year-old woman with unresectable pancreatic body carcinoma was admitted with epigastralgia with a sudden onset 6 h earlier. She had received chemotherapy for her cancer for 2 months. Physical examination showed mild anemia. Contrast-enhanced computed tomography showed dilated vessels in the bile duct walls connecting with dilated and tortuous vessels around the extrahepatic bile duct and portal vein obstruction due to invasion by a pancreatic body tumor. Endoscopic examination showed transpapillary hemorrhage suggesting bile duct hemorrhage. On endoscopic retrograde cholangiopancreatography, the lower bile duct was filled with a mass and the middle bile duct had filling defects with compression of the wall. To stop the bleeding, we placed a fully covered expandable metallic stent (EMS) at the middle to lower portion of the bile duct, and the hemorrhage stopped. Bile duct hemorrhage is not a common disorder. This report shows bile duct hemorrhage from bile duct varices can occur in patients with pancreatic carcinoma with portal obstruction and that fully covered EMS placement can stop the hemorrhage. Keywords Expandable metallic stent Bile duct hemorrhage Pancreatic cancer
Introduction Portal vein obstruction causes cavernous transformation and in rare instances bile duct varices [1], which can lead to C. Ueda M. Kikuyama (&) T. Ueda T. Kurokami Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-ando, Aoiku, Shizuoka, Shizuoka 420-8527, Japan e-mail: [email protected]
123
bile duct hemorrhage from invasive biliary tract procedures [2]. Bile duct hemorrhage can be treated with placement of an expandable metallic stent (EMS) [3], but reports about this treatment are rare. Here we report a case of pancreatic carcinoma and spontaneous hemorrhage from bile duct varices that we treated with fully covered EMS placement.
Case report A 64-year-old woman with unresectable pancreatic body carcinoma was admitted with epigastralgia with a sudden onset 6 h earlier. She had received chemotherapy for her cancer for 2 months. Physical examination showed mild anemia. Blood laboratory evaluations revealed decreased hemoglobin (Hb; 9.0 g/dL) with elevated hepatobiliary enzymes (AST 1295 U/L, ALT 969 U/L, ALP 679 U/L, cGTP 639 U/L, and total bilirubin 2.4 mg/dL). Plain computed tomography (CT) of the upper abdomen showed highly dense masses in the extrahepatic bile duct (Fig. 1). Contrast-enhanced CT performed 2 months earlier had showed dilated vessels in the bile duct walls connecting with dilated and tortuous vessels around the extrahepatic bile duct and portal vein obstruction due to invasion by a pancreatic body tumor (Fig. 2). The finding of vessel abnormalities had revealed bile duct varices and cavernous transformation. Endoscopic examination showed transpapillary hemorrhage suggesting bile duct hemorrhage (Fig. 3). On endoscopic retrograde cholangiopancreatography (ERCP), the lower bile duct with a diameter of 8 mm was filled with a mass and the middle bile duct had filling defects with compression of the wall (Fig. 4). Bile duct hemorrhage due to bile duct varices was considered to be
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possible. To stop the bleeding, we placed a fully covered EMS (10 9 80 mm, WallflexTM Biliary RX; Boston Scientific) at the middle to lower portion of the bile duct (Fig. 5) and the hemorrhage stopped. The day after the endoscopic treatment, the symptoms and the abnormal blood laboratory measurements showed improvement and the Hb level had not worsened. During a 4-month follow-up after the procedure, the symptoms have not recurred and the blood count and liver enzymes have recovered to the normal range.
Discussion
Fig. 1 Plain abdominal CT showing highly dense masses in the lower extrahepatic bile duct (arrow)
Bile duct hemorrhage is not a common disorder and is seen in patients with gallstones, gallbladder carcinomas, biliary pseudoaneurysms, or tendency for hemorrhage. Bile duct varices also cause bile duct hemorrhage.
Fig. 2 Contrast-enhanced CT showing dilated vessels in the bile duct walls (a, b; arrow) connecting with dilated and tortuous vessels around the extrahepatic bile duct (c; arrow) and portal vein obstruction due to invasion by a pancreatic body tumor (d; arrowhead)
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Fig. 3 Endoscopic examination showing transpapillary hemorrhage
Fig. 4 ERCP showing a mass in the lower bile duct (a; arrow) and filling defects with compression of the wall at the middle bile duct (b; arrow head)
Bile duct varices were first described by using ERCP and correlating it with angiography in a patient with pancreatic carcinoma in 1982 [4], but have been rarely reported [1, 2, 4–8]. Varices of the hepatoduodenal ligament and the porta hepatis are common sequelae of chronic portal vein thrombosis known as cavernous transformation. Bile duct varices are dilated vessels within the bile duct wall connecting with the cavernous transformation [2]. The diagnosis of bile duct varices depends on the findings of ERCP and CT. Filling defects of the bile duct can be seen on cholangiography. Compression by dilated vessels in the bile duct wall is responsible for these findings, which should be distinguished from those by bile duct tumors [6]. CT helps to distinguish these two conditions by showing the dilated vessels in the bile duct connected with cavernous transformation [2]. Findings of irregular bile duct strictures are called a pseudo-choriocarcinoma sign [6]. Cholangioscopic examination techniques have advanced and bile duct varices can now be recognized with cholangioscopy. However, these rare conditions become clinically important when they cause bile duct hemorrhage. Cholangioscopic examination is not considered to be useful for bile duct varices in patients with portal vein obstruction. Once hemorrhage occurs, there is no time to perform cholangioscopic examination because endoscopic papillotomy with introduction of a cholangioscope during hemorrhage is risky given the patient’s poor condition, and the bile duct lumen filled with blood cannot be observed due to its small diameter even if saline is injected through its working channel. We recognized the vessel abnormalities in the present case with contrast-enhanced CT of the upper abdomen,
which originated from the upper portion of the superior mesenteric vein, passed through the head of the pancreas, and continued into the portal vein at the porta hepatis forming cavernous transformation and connecting with dilated vessels in the bile duct wall. Filling defects of the middle bile duct on cholangiography were considered to be compressions by the dilated vessels called bile duct varices [8], causing bile duct hemorrhage. No other abnormalities were observed on contrast-enhanced CT that could potentially cause bile duct hemorrhage. We placed a fully covered EMS to put pressure upon the bile duct wall to stop the hemorrhage, and we achieved our goal. In this setting, a fully covered EMS is more favorable than a non-covered EMS, because varices could protrude through the stent interstices and cause hemorrhage if a noncovered EMS was used [1]. Furthermore, the diameter of an EMS should be larger than that of a bile duct, because of the necessity to oppress the bile duct. Fully covered EMS placement to stop hemorrhage from the bile duct in a case of post-endoscopic sphincterotomy (EST) was previously described [3], but there is no report using this procedure for bile duct varices. Hemorrhage from varices is commonly treated with endoscopic injection sclerotherapy when varices are located at the esophagus, stomach, duodenum, or the cholangio-jejunal anastomosis [9]. However, sclerotherapy with cholangioscopy under hemorrhage is impossible because cholangioscopic examination is hard to perform for reasons described above. On the other hand, EMS placement was reported to treat hemorrhage from esophageal varices [10]. Endoscopic injection sclerotherapy and endoscopic variceal ligation are accepted treatments for the hemorrhage. EMS placement is
123
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83
Fig. 5 A fully covered EMS was placed at the middle to lower portion of the bile duct (a) with the lower end in the duodenal cavity (b)
an alternative treatment. EMS placed at the esophagus is easy to migrate due to esophageal peristalsis, and EMS placement does not have a role to eradicate esophageal varices or to prevent recurrence of hemorrhage. Transjugular intrahepatic portosystemic shunt placement as interventional radiology (IVR) was reported to be effective in treating hemorrhage from bile duct varices [11]. Generally, in patients with gastrointestinal hemorrhage, endoscopic hemostatic procedures should be the first-line treatment to stop bleeding, and IVR remains to be selected when endoscopic hemostasis fails because preparation of IVR takes time and cannot always be performed in all hospital. In patients with bile duct hemorrhage, endoscopic treatment should be prior to IVR for the same reasons, i.e., if the hemorrhage could be treated with EMS placement or balloon compression through the duodenal papilla. This report shows bile duct hemorrhage from bile duct varices can occur in patients with pancreatic carcinoma with portal obstruction and fully covered EMS placement can stop the hemorrhage. Conflict of interest of interest.
The authors declare that they have no conflict
References
2. Chow L, Jeffrey Jr RB. Intramural varices of the bile duct: an unusual pattern of cavernous transformation of the portal vein. Am J Roentgenol. 1999;173:1255–6. 3. Itoi T, Yasuda I, Doi S, Mukai T, Kurihara T, Sofuni A. Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding. Endoscopy. 2011;43:369–72. 4. Williams SM, Burnett DA, Mazer MJ. Radiographic demonstration of common bile duct varices. Gastrointest Radiol. 1982;7:69–70. 5. Song MH, Kim MH, Lee SK, Lee SS, Seo DW. Bile duct varices. Gastrointest Endosc. 2004;59:869–70. 6. Bayraktar Y, Balkanci F, Kayhan B, Arslan S, Koseoglu T, Ozdemir A, et al. Bile duct varices or ‘‘pseudo-cholangiocarcinoma sign’’ in portal hypertension due to cavernous transformation of the portal vein. Am J Gastroenterol. 1992;87:1801–6. 7. Ikegami T, Matsuzaki Y, Saito Y, Nishi M, Tanaka N, Osuga T, et al. Endoscopic diagnosis of common bile duct varices by percutaneous trans-hepatic choledochoscopy: differential diagnosis from bile duct carcinoma. Gastrointest Endosc. 1994;40: 637–40. 8. Tighe M, Jacobson I. Bleeding from bile duct varices: an unexpected hazard during therapeutic ERCP. Gastrointest Endosc. 1996;43:250–2. 9. Ito T, Segawa T, Kanematsu T. Successful endoscopic injection sclerotherapy for bleeding from bile duct varices. Surg Today. 1997;27:174–6. 10. Hubmann R, Bodlaj G, Czompo M, et al. The use of selfexpanding metal stent to treat acute esophageal variceal bleeding. Endoscopy. 2006;38:896–901. 11. Gorgul A, Kayhan B, Dogan I, Unal S. Disappearance of the pseudo-cholangiocarcinoma sign after TIPPS. Am J Gastroenterol. 1996;91:150–3.
1. Cvetkovski B, Kurtz RC. Hemobilia in advanced pancreatic cancer with portal vain obstruction and a metal endobiliary stent: a case report. Gastrointest Endosc. 1999;50:420–2.
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