Upper Gastrointestinal Hemorrhage Secondary to Erosion of a Biliary Wallstent in a Woman with Pancreatic Cancer

• Introduction
• Case Report
• Discussion
• References

A 77-year-old patient with unresectable pancreatic adenocarcinoma sustained a life-threatening, upper gastrointestinal hemorrhage 1 month after placement of a biliary Wallstent. Radiographic and endoscopic studies revealed a choledocho-arterio-enteric fistula caused by erosion of the stent through the posterior duodenal wall. The patient was treated successfully with arterial embolization. This represents an unusual case of arterial bleeding with choledocho-arterio-enteric fistulization into the duodenum subsequent to biliary stent erosion.

Introduction

Stents are commonly used to alleviate biliary obstruction, most often in cases of malignancy. Though relatively less invasive than open surgical procedures, biliary stenting is not without risk. We present a case of an unusual complication related to the use of a Wallstent placed for palliative relief of neoplastic biliary obstruction.

Case Report

A 77-year-old woman with a previous medical history of hypertension was diagnosed by endoscopic ultrasound with stage T4 N2 M1 unresectable pancreatic adenocarcinoma after presenting with symptoms of biliary obstruction. A computed tomographic scan showed the tumor was present in the pancreatic head and encased the porta hepatis. A plastic stent was placed transhepatically to relieve the obstruction and she underwent palliative radiation therapy. No other surgical procedures or chemotherapy were attempted at that time. The patient did well until she presented 3 months later with recurrent jaundice and stent occlusion. The biliary stent was removed and a combined percutaneous endoscopic procedure was used to place a Wallstent (Schneider USA Inc., Minneapolis, Minnesota) across the tumor to relieve the obstruction. The patient did well and was discharged. She was re-admitted with massive upper gastrointestinal bleeding 1 month later and was transfused with 10 units of packed red blood cells, then transferred to our institution for further management.

Once admitted to our institution, the patient continued to bleed and required an additional 4 units of packed red blood cells. Esophagogastroduodenoscopy (EGD) showed that the metallic stent had eroded through the common bile duct and the posterior wall of the duodenal bulb (Figure [1]). An upper gastrointestinal series showed obstruction of the postbulbar duodenum with narrowing of the second and third portions. Contrast entered the stent in the duodenum proximal to the obstruction, coursed through the stent, and emerged in the distal second portion of the duodenum (Figure [2]). The next day the patient developed massive bleeding and was referred for emergent angiography. Selective common hepatic angiography showed complete occlusion of the gastroduodenal and hepatic arteries without extravasation. Because of the patient's recent massive bleeding, the occlusion was probed with a guide-wire until free flow of intravenous contrast into the duodenum was demonstrated (Figure [3]). This arterioenteric fistula was then permanently occluded with multiple embolization coils. The patient underwent gastrojejunal bypass to palliate her gastric outlet obstruction with no subsequent gastrointestinal bleeding. She was doing well 6 months later, after which she was lost to follow-up.

Discussion

Stenting has become a commonly employed method of treatment for both benign and malignant biliary (as well as pancreatic) duct obstruction. Two styles of endoprostheses commonly used in the USA are plastic and metallic stents. Both varieties provide excellent means to secure adequate drainage of the biliary tree, but in the last 5 years metallic stents have become more popular since they have been shown to be less prone to obstruction [1] [2] . Self-expanding metallic stents can be mounted on a 7-Fr delivery catheter and can expand to 30 Fr upon deployment. Metallic stent placement may be performed either by the percutaneous transhepatic or endoscopic route. Complications of stents include migration, perforation, hemorrhage, and obstruction [1] [2] [3] .

Stent-related hemorrhage is uncommon (1.25 % in one study [2]) and may be classified into four settings. The first is post-procedure bleeding and is usually self-limited, responding to local measures. This type of hemobilia may be related to technique, systemic anticoagulation, or tissue friability secondary to tumor invasion. The second type of hemobilia occurs later and may be related to local ductal epithelial irritation causing only capillary oozing, and therefore may not require immediate intervention. The third type of bleeding is caused by the distal end of the stent eroding into the adjacent bowel wall. The last and most serious cause of bleeding is stent erosion into adjacent vascular structures causing massive hemorrhage [4] [5] . Vessels involved include the hepatic, gastroduodenal, and pancreaticoduodenal arteries, all of which can be successfully embolized using transcatheter techniques. Invasion of metastatic adenocarcinoma plays a role in compromising the surrounding tissue and, in some cases, it may be difficult to tell whether the neoplasm or the stent (or both) caused the erosion. Radiation therapy may be a contributing factor. Our patient is the second case reported in the literature of stent-related hepatic artery fistulization, and this is the only report of a choledocho-arterio-enteric fistula associated with a self-expanding biliary stent. Patients such as these may need emergent EGD or angiography depending upon the availability of these services at a particular institution. In some cases, surgery may be needed to provide laparatomy if other techniques fail.

References

• 1 Adam A, Chetty N, Roddie M, et al. Self-expanding stainless steel endoprostheses for treatment of malignant bile duct obstruction.  Am J Roentgenol. 1991;  156 321-325
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• 2 Rossi P, Bezzi M, Rossi M, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients.  J Vasc Interv Radiol. 1994;  5 279-285
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• 3 Smilanich R P, Hafner G H. Complications of biliary stents in obstructive pancreatic malignancies: a case report and review.  Dig Dis Sci. 1994;  39 2645-2649
  PubMedSearch in Google Scholar
• 4 Ee H, Laurence B H. Haemorrhage due to erosion of a metal biliary stent through the duodenal wall.  Endoscopy. 1992;  24 431-432
  PubMedSearch in Google Scholar
• 5 Monroe P S, Deeter W T, Rizk P. Delayed hemobilia secondary to expandable metal stent.  Gastrointest Endosc. 1993;  39 190-191
  CrossrefPubMedSearch in Google Scholar

G. R. Lichtenstein,M.D. 

Gastroenterology Division University of Pennsylvania School of Medicine Hospital of the University of Pennsylvania

Third Floor Ravdin Building 3400 Spruce Street Philadelphia, PA 19104-4283 USA

Fax: Fax:+ 1-215-349-5915

Email: E-mail:grl@mail.med.upenn.edu

References

• 1 Adam A, Chetty N, Roddie M, et al. Self-expanding stainless steel endoprostheses for treatment of malignant bile duct obstruction.  Am J Roentgenol. 1991;  156 321-325
  PubMedSearch in Google Scholar
• 2 Rossi P, Bezzi M, Rossi M, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients.  J Vasc Interv Radiol. 1994;  5 279-285
  CrossrefPubMedSearch in Google Scholar
• 3 Smilanich R P, Hafner G H. Complications of biliary stents in obstructive pancreatic malignancies: a case report and review.  Dig Dis Sci. 1994;  39 2645-2649
  PubMedSearch in Google Scholar
• 4 Ee H, Laurence B H. Haemorrhage due to erosion of a metal biliary stent through the duodenal wall.  Endoscopy. 1992;  24 431-432
  PubMedSearch in Google Scholar
• 5 Monroe P S, Deeter W T, Rizk P. Delayed hemobilia secondary to expandable metal stent.  Gastrointest Endosc. 1993;  39 190-191
  CrossrefPubMedSearch in Google Scholar

G. R. Lichtenstein,M.D. 

Gastroenterology Division University of Pennsylvania School of Medicine Hospital of the University of Pennsylvania

Third Floor Ravdin Building 3400 Spruce Street Philadelphia, PA 19104-4283 USA

Fax: Fax:+ 1-215-349-5915

Email: E-mail:grl@mail.med.upenn.edu