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Updated: Oct 29, 2025
Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction
Published on: March 25, 2022
A case with massive hemobilia long-term after internal drainage surgery for congenital biliary dilation
Shunryo Minezaki1, Takeyuki Misawa2, Makoto Watanabe1
1Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8606, Japan.
Insights
Internal drainage surgery for congenital biliary dilation (CBD) can lead to delayed complications, including bile duct bleeding and cancer. This case highlights the long-term risks associated with this obsolete procedure.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Hepatobiliary Surgery
Background:
- Congenital biliary dilation (CBD) surgery has evolved, with extrahepatic bile duct resection and choledochojejunostomy now standard.
- Internal drainage surgery (IDS), an older CBD treatment, is obsolete due to cancer risks but its long-term pathology remains unclear.
Purpose of the Study:
- To report a rare case of severe bile duct bleeding and incidental cholangiocarcinoma 62 years after IDS for CBD.
- To emphasize the potential long-term risks of remnant bile ducts after obsolete IDS procedures.
Main Methods:
- A case report of an 82-year-old woman presenting with hemorrhagic shock due to gastrointestinal bleeding.
- Diagnosis of pseudoaneurysm rupture in the remnant bile duct after prior IDS for CBD.
- Management involved emergency transcatheter arterial embolization (TAE) followed by elective bile duct resection and choledochojejunostomy.
Main Results:
- Successful hemostasis achieved via TAE for life-threatening bile duct bleeding.
- Pathological examination revealed chronic inflammation and incidentally detected early-stage cholangiocarcinoma (Tis, N0, M0, pStage 0).
Conclusions:
- Long-standing chronic inflammation in remnant bile ducts after IDS poses risks of life-threatening bleeding and carcinogenesis.
- Accurate patient history regarding prior CBD surgical procedures is crucial for diagnosing hemobilia.
Background:
Currently, there is an unwavering consensus that the standard surgery for congenital biliary dilation (CBD) is extrahepatic bile duct resection and choledochojejunostomy. However, decades prior, choledochocyst-gastrointestinal anastomosis without extrahepatic bile duct resection (internal drainage surgery, IDS) was preferred for CBD because of its simplicity. Currently, there is almost no chance of a surgeon encountering a patient who has undergone old-fashioned IDS, which has been completely obsolete due to the risk of carcinogenesis from the remaining bile duct. Moreover, the pathological condition long after IDS is unclear. Herein, we report a case of life-threatening bile duct bleeding as well as carcinoma of the bile duct 62 years after IDS in a patient with CBD.
Case Presentation:
An 82-year-old Japanese woman with hemorrhagic shock due to gastrointestinal bleeding was transferred to our hospital. She had a medical history of unspecified surgery for CBD at the age of 20. Based on imaging findings and an understanding of the historical transition of the surgical procedure for CBD, the cause of gastrointestinal bleeding was determined to be rupture of the pseudoaneurysm of the dilated bile duct that remained after IDS. Hemostasis was successfully performed by transcatheter arterial embolization (TAE) in an emergency setting. Then, elective surgery for extrahepatic bile duct resection and choledochojejunostomy was performed to prevent rebleeding. Pathological examination revealed severely and chronically inflamed mucosa of the bile duct. Additionally, cholangiocarcinoma (Tis, N0, M0, pStage 0) was incidentally revealed.
Conclusion:
It has been indicated that not only carcinogenesis, but also a risk of life-threatening bleeding exists due to long-lasting chronic inflammation to the remnant bile duct after IDS for CBD. Additionally, both knowledge of which CBD operation was performed, and an accurate clinical history are important for the diagnosis of hemobilia.
