A 73-year-old man with previous admission history of laparoscopic cholecystectomy (LC) due to calculous cholecystitis and endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct stones removal and endoscopic retrograde biliary drainage (ERBD) using a plastic biliary stent presented with melena and epigastric pain in the emergency department. He underwent upper gastrointestinal endoscopy and abdominal computed tomography (CT) scan with contrast enhancement in the emergency department and was confirmed to be hemobilia and distal migration of previously inserted a plastic biliary stent (Fig. 1). He had admitted to division of gastroenterology and underwent ERCP with common bile duct hematomas removal and ERBD change (Fig. 2). After the ERCP procedure procedure, hemobilia was controlled and hemoglobin levels were normalized. However, after 1 week of stable and no bleeding period, hemobilia and melena was recurred. Follow-up ERCP showed hemobilia (Fig. 3), and the patient underwent selective angiography for gastroduodenal artery using microcatheter and Meister guidewire (Asahi Intecc, Nagoya, Japan) with subsequent embolization for small pseudoaneurysm of pancreaticoduodenal artery with 1.5 mL of lipiodol (Guerbet Korea, Seoul, Korea) mixed with 0.5 mL of glue (Fig. 4). After this intervention, the patient was recovered from hemobilia and discharged thereafter 2 days of hospital admission.

Hemobilia and vascular injuries are among the most important—albeit not necessarily the most common—complications of LC due to the high morbidity and mortality associated with this complication.^1,2 Although, the most common causes of hemobilia after LC was iatrogenic arterial injury followed by ligation. Approximately 10% of all the reported cases of hemobilia after LC are secondary to iatrogenic hepatic artery pseudoaneurysm.³

If common bile duct stones with obstructive cholangitis were identified before LC, ERCP procedure with endoscopic sphincterotomy (EST), common bile duct stones removal and drainage procedure such as ERBD could be applied to the patient. A few case reports have described hepatic or intrahepatic artery pseudoaneurysm caused directly by a plastic biliary stent.^4–6 In the present case, we inserted an 7-Fr plastic biliary stent (double pigtailed form) for the treatment of suppurative cholangitis associated with common bile duct stones, and the patient sequentially underwent LC for the treatment of calculous cholecystitis. After 8 weeks of ERBD insertion, the patient showed upper gastrointestinal bleeding due to hemobilia and subsequent selective angiography showed small pseudoaneurysm in pancreaticoduodenal artery. It is reasonable to assume that the mechanism of pancreaticoduodenal artery pseudoaneurysm in the present case was erosion of pancreaticoduodenal artery by the plastic biliary stent because the pseudoaneurysm was located at the critical proximal end of the migrated plastic biliary stent, implying a direct cause.

Pancreaticoduodenal artery pseudoaneurysm induced by a plastic biliary stent is extremely rare and only one case in the present report was identified by literature searching. It would be reasonable to remove a plastic biliary stent if the symptoms and signs of suppurative cholamgitis were gone and especially in cases of distally migrated plastic biliary stent but was caught in the distal common bile duct.

In cases of upper gastrointestinal bleeding after the insertion of a plastic biliary stent, a rare cause of hemobilia caused by hepatic artery or pancreaticoduodenal artery pseudoaneuryms formed by direct erosion of proximal end of a plastic biliary stent should be deemed in differential diagnosis of upper gastrointestinal bleeding. Appropriate diagnostic and therapeutic modalities such as hepatic angiography and embolization should be considered in these rare cases.