Endoscopic ultrasound-guided coil embolization and glue injection of bleeding bile duct varices causing gastrointestinal hemorrhage.

BACKGROUND AND AIMS: Bleeding bile duct varices are rare vascular communications between the portal venous system and the biliary tree. They may arise from portal vein thrombosis, malignancy, or endoscopic injury and often present with life-threatening hemobilia. We describe a case of choledochal varices bleeding in a patient with hepatocellular carcinoma (HCC) successfully managed with endoscopic ultrasound-guided coil embolization and glue injection. METHODS: A 62-year-old man with hepatitis C virus cirrhosis and portal vein tumor thrombus presented with hematochezia and right upper quadrant pain. He underwent prior stereotactic body radiation and was not a transplant candidate. Initial laboratory tests showed hemoglobin of 12 g/dL. CT angiogram revealed portal venous collateralization; esophagogastroduodenoscopy and colonoscopy were unrevealing. After a postcolonoscopy episode of brisk hematochezia and hemodynamic instability, small-bowel enteroscopy showed active bleeding from the ampulla. RESULTS: Endoscopic retrograde cholangiopancreatography revealed hemobilia from the bile duct, and a covered metal stent was placed. EUS identified a large portal-system varix encasing the bile duct, which was successfully obliterated using coil and glue embolization. CONCLUSIONS: Biliovenous fistulas are a rare but serious cause of hemobilia in HCC. EUS-guided embolization offers effective, definitive therapy after initial stabilization with biliary stenting. Timely diagnosis and intervention are critical.