Intraductal bleeding varices A rare finding of single-operator cholangioscopy, for a patient with distal biliary stricture and portal biliobethy. Sclerosing cholangitis, colitical athiasis, iatrogenic bile duct injury, infectious causes, chronic pancreatitis, and congenital anomalies are the most common causes of benign biliary strictures. Vascular-related diseases, including portal hypertensive biliobethy, are another uncommon cause of benign biliary strictures. Portal biliobethy is a rare condition, that involves cholangiographic abnormalities in relation to portal cavernoma, and collaterals around the bile duct. The concurrent ischemic injury and structural changes of the bile duct wall, may result in biliary strictures, colitical athiasis, and cholangitis. Most patients with portal biliobethy are asymptomatic and do not require any treatment. Abdominal ultrasound, computed tomography, magnetic resonance imaging, and endoscopic ultrasound, are among the currently available imaging techniques, however, all are only and not diagnostic. Cholangioscopy is one of the most valuable diagnostic techniques, for indeterminate biliary strictures, with high sensitivity, specificity, and accuracy of its visual impression. The current new digital version of the single operator cholangioscopy, provides a better image quality, and wider endoscopic field of view. Herein, we present a rare case of intraductal active variceal hemorrhage, visualized by digital single operator cholangioscopy, in a cirrhotic patient. 55 years old man presented with jaundice and intermittent abdominal pain. He was diagnosed with history of bilharziases-induced chronic liver disease, complicated with portal hypertension and upper gastrointestinal bleeding with previous variceal band ligation, and prior splenectomy. Laboratory data were unremarkable, but total bilirubin was highly elevated. Magnetic resonance cholangiopancreatography showed a distal CBD stricture with proximal biliary dilatation, with no evidence of any pancreatic masses. Further endoscopic evaluation has included esophagogastroduodenoscopy, that showed small non-bleeding esophageal, gastroesophageal and duodenal varices. Endoscopic ultrasound revealed, proximally dilated common bile duct with normal caliber distally, and two small intraductal stones, with grossly free ampullary region. Lastly, during endoscopic retrograde cholangiopancreatography, cholangiogram revealed dilated proximal biliary tract, with small filling defects inside, followed by extraction of two stones after biliary sphincterotomy. Persistent distal biliary stricture on closed cholangiogram was noted. Cholangioscopy revealed that proximal CBD was grossly free, while the distal CBD showed marked narrowing. Surprisingly, the mucosal lining started to ooze, with a continuous active fresh bleeding for the next few seconds. Furthermore, the mucosa was shown to have risky varices with red signs. Varices started to flatten with the pressure generated by water irrigation. And then the bleeding stopped. Management. Biliary stenting was carried out, firstly by plastic stent, with secured active bleeding, and good biliary drainage. Later, stent was replaced, by fully covered self-expandable metal stent. Patient was referred for Interventional Radiology Department, for further transjugular intrahepatic portosystemic shunt, as a temporary step before evaluation for liver transplantation. Conclusions. Portal biliobethy is a rare cause of biliary stricture, and subsequent clinical scenarios. High rate of suspicion and awareness, should be given for suspected cases, before invasive procedures like brush cytology, or wire-guided biopsy for subs-tissue sampling. Digital single operator cholangioscopy provides a magnificent high-definition images, enabling final diagnosis in such cases.

intraductal bleeding varices

cholangioscopy

portal biliopathy

biliary stricture

biliary stenting