A case of hemobilia caused by pancreatic metastasis of renal cell carcinoma treated with a covered metallic stent

Abstract

We present the case of an 86-year-old man who had undergone left nephrectomy for renal cell carcinoma (clear cell carcinoma) 22 years ago. He visited the emergency department complaining of right hypochondrial pain and fever. He was eventually diagnosed with acute cholangitis. Abdominal contrast-enhanced computed tomography showed multiple tumors in the pancreas. The tumor in the pancreatic head obstructed the distal bile duct. Endoscopic retrograde cholangiopancreatography detected bloody bile juice flowing from the papilla of Vater. Therefore, he was diagnosed with hemobilia. Cholangiography showed extrinsic compression of the distal bile duct; a 6 Fr endoscopic nasobiliary drainage tube was placed. Endoscopic ultrasound showed that the pancreas contained multiple well-defined hypoechoic masses. Endoscopic ultrasound-guided fine-needle aspiration was performed using a 22 G needle. Pathological examination revealed clear cell carcinoma, and the final diagnosis was pancreatic metastasis of renal cell carcinoma (RCC) causing hemobilia. A partially covered metallic stent was placed in the distal bile duct. Consequently, hemobilia and cholangitis were resolved.

Keywords: Hemobilia; Metallic stent; Renal cell carcinoma.

Fig. 1

a, b Contrast-enhanced computed tomography showed multiple tumors in the pancreas (arrow). c The intrahepatic bile duct was dilated

Fig. 2

a Magnetic resonance imaging showed multiple tumors in the pancreas with heterogeneously low signal intensity on the T1-weighted image. Bile in the common bile duct and gallbladder neck has high intensity, which suggests hemobilia. b Pancreatic masses have rather low intensity on T2WI, suggesting intratumor bleeding. Area with high intensity in pancreas head mass is considered as tumor necrosis

Fig. 3

Diffusion-weighted magnetic resonance imaging (b-factor = 1000 s/mm2) showed multiple tumors in the pancreas with a high signal intensity. Apparent diffusion coefficient map revealed pancreatic tumors with low intensity

Fig. 4

Endoscopic retrograde cholangiopancreatography findings. a Hemobilia was observed after biliary cannulation. b Cholangiography via the endoscopic naso-biliary drainage revealed that the distal bile duct was extrinsically compressed by the tumor (yellow arrow)

Fig. 5

Endoscopic ultrasound showed a multiple well-defined hypoechoic masses in the pancreas, and b color Doppler ultrasound showed abundant blood flow inside the masses

Fig. 6

Pathological findings of the specimen obtained by endoscopic ultrasound-guided fine needle aspiration. Hematoxylin–eosin staining revealed clear cell carcinoma with a clear cytoplasm and rich sinusoidal vasculature

Fig. 7

a After diagnosis, endoscopic retrograde cholangiopancreatography was performed, and a partially covered self-expandable metallic stent was placed. b Cholangiography revealed that the stenosis of the middle bile duct improved