Endoscopic management of hemobilia in the setting of hepatic Kaposi sarcoma using intrabiliary epinephrine. Hemobilia is an uncommon cause of GI bleeding that can result in biliary obstruction and death. Management centers on achieving hemostasis and clearing the biliary tree of blood, which often requires IR-guided therapy. Endoscopic therapy can play a role in certain patients. Previous studies have demonstrated the efficacy of endoscopic therapy for hemobilia related to post-phenotomy bleeding, as well as biliary stent placement for hemobilia arising from the distal biliary tree. Kaposi sarcoma is an angioproliferative malignancy that is most commonly seen in immunocompromised patients, such as those with AIDS. The GI tract is commonly involved, with 12 to 24% of patients having hepatic involvement, with biliary tract involvement being rare. Hepatobiliary involvement manifests as periportal liver lesions, bile duct strictures and dilation, and periportal lymphadenopathy. We present the case of a 42-year-old man with AIDS and hepatic Kaposi sarcoma who developed severe hemobilia. Six months prior to presentation, he presented with obstructive jaundice. Workup at that time revealed numerous periportal hepatic lesions, an ill-defined soft tissue portohepatous lesion, and multifocal strictures of the common hepatic and intrahepatic bile ducts. Biopsy of a periportal lesion confirmed Kaposi sarcoma. At that point, he underwent an ERCP with placement of multiple plastic intrahepatic bile duct stents with clinical improvement. Here, you can appreciate bilobar liver lesions on both CT and MRI imaging modalities. One month prior to his current presentation, the patient presented with cholangitis due to stent occlusion, at which point his stents were exchanged with subsequent clinical improvement. He was now admitted to the hospital with fevers, worsening anemia, elevated liver enzymes, and melanoma, all concerning for cholangitis with suspected hemobilia. He was then admitted to the hospital with a stent occlusion. After initial stabilization, ERCP was performed, which demonstrated three visibly occluded plastic stents, and a large, fresh clot was seen at the papilla. All three plastic stents were removed from the biliary tree, at which point massive hemobilia ensued. During the procedure, a large amount of hemoglobin was removed and a large amount of hemoglobin ensued. During the procedure, IR was consulted, as the patient was felt to need IR embolization. IR requested a CT angiogram, but given that the patient was actively bleeding, an attempt was made at endoscopic management. Biliary access was obtained with a stiff guide wire. Biliary access and demonstrated a common hepatic duct structure, segmental intrahepatic bile duct dilation, and multiple filling defects. Clots were removed with balloon extraction, but hemobilia persisted. Due to the volume of blood, the duodenoscope clogged and required exchange to a new scope. The extraction balloon was then advanced into the left intrahepatic bile duct, and the balloon was inflated to nine millimeters. With the balloon inflated, 10 milliliters of 1 to 10,000 epinephrine was instilled into the biliary tree and held in place for 10 minutes. The bleeding had slowed, but persisted. With the extraction balloon inflated to 12 millimeters at the bifurcation, another 10 milliliters of 1 to 10,000 epinephrine was instilled within the biliary tree and held in place for five minutes, resulting in hemostasis. One 10 millimeter by eight centimeter fully covered self-expanding metal stent was placed into the common bile duct just below the bifurcation, and a seven French by 10 centimeter plastic double pigtail stent was placed into the right intrahepatic bile duct to prevent migration of the fully covered stent. During the procedure, the patient remained hemodynamically stable when transfused two units of red blood cells. Given that the patient stopped bleeding, I.R. elected not to proceed with embolization. Five days later, the patient had recurrent melanoma. On imaging, it appeared the biliary stent had migrated. The patient was taken for an I.R. angiogram and was found to have an eight millimeter right hepatic artery pseudoaneurysm. He underwent coil embolization of the proximal right hepatic artery. After a prolonged ICU stay, the patient recovered. He continues to be on antiretroviral therapy and doxorubicin and remains stent free at seven month follow-up. Hemobilia is a life-threatening cause of GI bleeding. While endoscopic therapy is the cornerstone of management for hemobilia related to biliary sphincterotomy, hemobilia that arises from the proximal biliary tree is more difficult to manage endoscopically and often requires I.R. guided therapy. Intrabiliary installation of epinephrine was successful for the management of hemobilia arising from the proximal biliary tree, allowing for hemostasis and stabilization of the patient. In conclusion, intrabiliary installation of epinephrine can be used for endoscopic management of hemobilia and can allow for temporization of bleeding until definitive embolization therapy can be performed. Given the widespread availability and ease of use, installation of epinephrine should be considered as a treatment modality in patients with hemobilia undergoing ERCP.

Hemobilia

Hepatic Kaposi sarcoma

Intrabiliary epinephrine

ERCP

Endoscopic intervention