Hemobilia Due to Spontaneous Arterioportal Fistula in a Patient With Liver Abscess: A Rare Presentation

Abstract

Hemobilia is a rare cause of gastrointestinal bleeding, most commonly resulting from trauma or iatrogenic injury. Vascular complications such as arterioportal fistula (APF) are extremely uncommon, especially when occurring spontaneously in the setting of a liver abscess. We report a case of a 59-year-old man who presented with fever, abdominal pain, and later developed melena and biliary obstruction after percutaneous drainage of a presumed amoebic liver abscess. Endoscopic retrograde cholangiopancreatography revealed active bleeding from the biliary orifice, confirming hemobilia. Computer tomography angiography identified an APF in segment VIII of the liver. The patient was successfully managed with endoscopic stenting followed by transarterial coil and glue embolization of APF, resulting in complete resolution of symptoms. This case underscores the importance of maintaining a high index of suspicion for vascular complications like APF in patients with liver abscesses who develop signs of gastrointestinal bleeding and biliary obstruction. A multidisciplinary, image-guided approach is essential for prompt diagnosis and life-saving management.

Keywords: arterioportal fistula (APF); endoscopic retrograde cholangiopancreatography (ERCP); hemobilia; transarterial coil and glue embolization.

Figure 1.

Showing ultrasound whole abdomen picture of a large ill-defined lesion with low-level internal echoes in segments VII and VIII 67 × 63 × 57 mm; volume ∼129 cc suggestive of liver abscess.

Figure 2.

Endoscopic ultrasound image revealed a dilated common bile duct with echogenic contents.

Figure 3.

Endoscopic image from endoscopic retrograde cholangiopancreatography showing a bulging black lesion at the ampulla of Vater, the shiny smooth surface indicates a submucosal collection or hemobilia draining through papilla.

Figure 4.

The arterial phase hyperintensity in segment VIII represents arterioportal fistula-related shunting, manifesting as a transient perfusion abnormality rather than a true focal lesion.

Figure 5.

Showing computer tomography arterial phase imaging with simultaneous opacification of segment VIII hepatic artery and segment VIII portal vein, depicting direct arterioportal fistula.

Figure 6.

Showing segment VIII hepatic arteriogram demonstrating hepatic arteriosclerosis segmental portal fistula (star marked) in the abscess containing segment. Pigtail catheter in abscess (arrow) and plastic biliary stent (arrow head).

Figure 7.

Showing embolization of arterioportal fistula with 2-mm coils followed by proximal glue embolization to prevent by proximal glue embolization to prevent glue from escaping into portal vein.