Iatrogenic hemobilia – Two successive episodes due to a lesion of the common hepatic duct and delayed intrapancreatic arterio-biliary fistula manifested with hemorrhagic shock and managed by emergency pancreatoduodenal resection

Abstract text (incl. references and figure legends)
Introduction Hemobilia is a rare cause and usually self-limiting of upper gastrointestinal bleeding. Its intermittent nature may lead to significant diagnostic delay. Rarely, the bleeding originates from the pancreas. To the best of our knowledge, we report a well-documented unique case of two successive life-threatening episodes of iatrogenic hemobilia. Case report The first episode of hemobilia was due to an iatrogenic lesion of the common hepatic duct during laparoscopic cholecystectomy. The contrast CT showed hematoma in the gallbladder fossa and dilated common bile duct filled with clots (Fig. 1). The common bile duct was filled with blood clots, and there was a lesion of 5 mm. The intervention was completed by Kehr drain. ERCP was performed later. Ten months later he was admitted for bleeding but no visible bleeding source was detected via FGDS, capsule endoscopy, and MRCP. During the fourth readmission due to massive life-threatening hemobilia, Quincke's classic triad was presented. The endoscopy showed a clot at the major duodenal papilla. The angiography revealed bleeding at the communication of superior and inferior pancreatoduodenal arteries. Because of the unstable hemodynamics, the patient was taken to the operative room. The cholangioscopy found a bleeding arterial vessel at the intra-pancreatic part of the common bile duct. Because of impossible embolization an emergency Traverso-Longmire pancreatoduodenal resection was performed. The patient had an uneventful recovery. The finding from the microscopic examination was compatible with an intrapancreatic arterio-biliary fistula (Fig. 2). Conclusion The diagnosis of hemobilia depends on a high index of suspicion because Quincke's classic triad is rarely seen. In life-threatening bleeding, the decision-making depends on hemodynamic stability. Angioembolization is the cornerstone of the treatment, whereas the surgery is reserved only for unstable hemodynamic or unsuccessful embolization cases. emergency pancreatic head resection is a procedure of last resort, it can be life-saving in cases with intractable bleeding due to intrapancreatic arteriobiliary fistula.

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