Emergency use of a covered metal stent for life-threatening hemobilia from an arterio-biliary fistula: a case report

Arterio-biliary fistula (ABF) is a rare, life-threatening cause of hemobilia, most often resulting from iatrogenic injury during hepatobiliary procedures such as ERCP or laparoscopic cholecystectomy. Its delayed and nonspecific presentation poses a significant diagnostic challenge. When massive bleeding occurs, conventional endoscopic hemostasis often fails, necessitating urgent alternative interventions. A 39-year-old woman with a history of laparoscopic cholecystectomy presented with obstructive jaundice. Initial ERCP with sphincterotomy and plastic stent placement was performed. She subsequently developed massive hematemesis and hemorrhagic shock. Emergency endoscopy revealed torrential arterial bleeding from the common bile duct, suggestive of an ABF. Balloon tamponade failed. As a lifesaving measure, a fully covered self-expandable metal stent (FC-SEMS, 8 mm x 8 cm) was immediately deployed, achieving complete hemostasis and hemodynamic stabilization. Subsequent computed tomography angiography (CTA) confirmed a right hepatic artery pseudoaneurysm communicating with the biliary tree. The patient underwent successful coil embolization two days later. The metal stent provided effective bridging hemostasis with no rebleeding. The patient recovered fully. This case demonstrates that the emergency placement of a covered metal stent can be a rapid, effective, and lifesaving bridging endoscopic intervention for controlling catastrophic hemobilia from an ABF, serving as a crucial temporary measure until definitive transarterial embolization can be performed.