hemobilia after therapeutic endoscopy is most often caused by traumatic injury , such as manipulation of the instruments during the procedure . a classic triad of upper abdominal pain , upper gastrointestinal ( gi ) bleeding , and jaundice is present in patients with hemobilia , but only 22% of patients have all three symptoms . the onset of hemobilia commonly occurs within 4 weeks of bile duct injury , but the range of occurrence is widely variable . risk factors for delayed onset hemobilia include bile stasis , hepatic necrosis , and the formation of a slowly expanding pseudoaneurysm . biliary stent - related hemobilia following an endoscopic procedure has been reported much less often than hemobilia attributable to iatrogenic causes related to percutaneous liver procedures . until now , four cases related to an endoscopic and percutaneous approach have been reported and almost all of them occurred immediately or few days after the procedure . endoscopic retrograde cholangiopancreatography ( ercp ) is a relatively invasive procedure and may cause hemobilia ; however , it can be a useful tool for diagnosis and management of hemobilia . ercp - related biliary or duodenal perforation must be managed promptly , taking into account the patient s comorbidities and the type of perforation . endoscopic treatment with a biliary plastic stent can be done in cases of bile duct perforation , in patients of an advanced age . to our knowledge , delayed hemobilia secondary to endoscopic stent inserted for ercp - related perforation has not been reported until now . we recently managed a case of ercp - related bile duct perforation after the removal of common bile duct ( cbd ) stones that caused cholangitis . the perforation was successfully managed by endoscopic insertion of plastic biliary stents , but severe hemobilia was encountered approximately 5 weeks after the stent insertion and a repeated episode at 10 days after the removal of stents . a 75-year - old female patient presented to our emergency center with abdominal pain for the last 7 days . her past medical history included removal of cbd stones and a laparoscopic cholecystectomy for gallbladder stones in sam anyang hospital , 3 years before the current admission and total abdominal hysterectomy for uterine myoma 10 years before this admission . her vital signs were : blood pressure 110/70 mm hg , pulse rate 88 beats per minute , respiratory rate of 20 breaths per minute , and body temperature , 37.9c . physical examination showed an acute ill - looking appearance and tenderness without rebound in epigastrium and was otherwise unremarkable . initial laboratory findings were as follows : hemoglobin ( hb ) , 13.4 g / dl ; aspartate aminotransferase ( ast)/alanine aminotransferase ( alt ) , 522/1,236 iu / l ; alkaline phosphatase ( alp ) , 518 iu / l ; total bilirubin , 3.5 mg / dl ; blood urea nitrogen ( bun)/creatinine ( cr ) , 30/1.7 mg / dl ; and c - reactive protein , 115.2 mg / l . abdominal non - enhanced computed tomography ( ct ) due to renal impairment revealed a 15 mm calcified stone in her cbd , with proximal bile duct dilation and surgical clips around the gallbladder bed from the cholecystectomy ( fig . 1 ) . intravenous antibiotics were administered and ercp was performed . after extended biliary sphincterotomy and transpapillary balloon dilation up to 15 mm , several brown , the total procedure time was approximately 50 minutes and her vital signs including oxygen saturation were stable during the procedure . severe abdominal distension with pain was observed just after the procedure and a physical examination showed severe tenderness with rebound in the right upper quadrant . a post - ercp chest radiography obtained 15 minutes after the procedure showed a huge pneumoperitoneum in the right subphrenic area . after the removal of the nasobiliary drainage tube , emergency upper gi endoscopy was immediately performed ( 30 minutes after the ercp ) in order to detect the perforation site . however , no perforation was observed in the hollow viscus or sphincterotomy sites and it was assumed that the perforation was due to bile duct injury above the pancreas . a nasobiliary drainage tube used to lower the abdominal pressure after an injured bile duct is uncomfortable when used for several days in comparison with a biliary plastic stent . two indwelling biliary plastic stents ( one 8 cm pigtail type , the other 10 cm straight type ) were inserted into the right hepatic duct ( fig . we then informed the patient and her family about the possibility of an emergent surgery if her vital signs and symptoms will deteriorate . patient was recommended to withhold oral intake and received intravenous fluid with antibiotics for 4 days after the insertion of the stents . clinical course was favorable ; free air nearly disappeared and she resumed a liquid diet 6 days later . she was discharged 9 days after stone removal and the two stents were removed approximately 3 weeks later in a follow - up visit , as an outpatient . she continued to improve and had not experienced abdominal pain for 4 weeks after discharge . her vital signs were : blood pressure 80/50 mm hg , pulse rate 107 beats per minute , respiratory rate 18 breaths per minute , and body temperature 36.8c . she was very pale , anicteric , lethargic , and mildly disoriented . on physical examination , tenderness without rebound in the epigastric region was observed , but otherwise the results were unremarkable . laboratory findings were as follows : hb , 7.6 g / dl ; white blood cell count , 10,700/l ; ast / alt , 59/23 iu / l ; and bun / cr , 16/0.9 mg / dl . urgent upper gi endoscopy showed active bleeding from the ampullary orifice consistent with hemobilia ( fig . subsequent emergent hepatic angiography was performed while a blood transfusion was administered , in an effort to locate and embolize the source of the bleeding . selective right hepatic arteriography showed a fistula between the right posterior hepatic artery and the bile duct and the fistula was occluded by coil embolization . her vital signs stabilized after the procedure and her hb level increased to 10.2 g / dl , but massive and continuous hematochezia was observed 6 hours after the embolization . her hb then dropped to 4.6 g / dl and a second emergent hepatic angiography was performed . an angiogram of the right posterior hepatic artery showed the continued leakage of contrast solution into the bile duct , so further embolization was performed with a total of 10 coils , including the coils used in the first intervention ( fig . she stabilized after another blood transfusion and no further active bleeding was observed for 5 days after the second embolization , at which point she was discharged . iatrogenic ercp - related hemobilia is most common immediately after or within several days of the procedure ; delayed onset hemobilia can be due to continuous , chronic bile duct erosion and inflammation contributing to weakening of the bile duct , with injury to adjacent vessels , and eventual bleeding into the bile duct . bile duct perforation after ercp can be a cause of delayed onset hemobilia if the lesion is incompletely healed inflammatory bile duct weakening contributes to vessel injury and leads to bleeding into the bile duct , as in our case . perforation of the bile duct after ercp can be conservatively managed in patients with minor bile duct injury , but in the case of a relatively large pneumoperitoneum after ercp , as in our patient , it can be difficult to decide between surgery and endoscopic therapy with conservative management . after we confirmed through emergent upper gi endoscopic examination that there was no perforation of the bowel or sphincterotomy , biliary plastic stent insertion successfully treated the bile duct perforation . patient s pain was relieved and a decrease of free air was evident on chest radiography . the appropriate indwelling time of biliary stents after bile duct perforation is variable , but the appropriate time to remove the stent is more than 6 to 8 weeks . delayed hemobilia in our patient was probably caused by the ongoing inflammation from incomplete healing of the bile duct . this could contribute to the fistula formation between the bile duct and the hepatic artery and eventually bleeding , even though the patient seemed to have recovered completely at discharge and had no bleeding until 10 days after the removal of the stents . to our knowledge , there is insufficient data for a consensus on the optimal duration of biliary stenting , especially for plastic stents , if ercp - related bile duct perforation occurs . for metal stents , some researchers advocate a relatively long duration , ranging from 2 months to more than 6 months . although the removal of the stent was postponed for 6 to 8 weeks , whether hemobilia could have been prevented in this patient is not clear , but a long indwelling time of the stent might be beneficial for a complete healing of the bile duct . alternatively , direct injury due to the inserted biliary stent is less likely , especially since no bleeding was observed during hospitalization after the insertion of the stents and for 10 days after the removal of the stents . however , it is difficult to appreciate whether the previously inserted two stents ( 8 and 10 cm in length ) were located in the right anterior or posterior hepatic ducts because of the inaccuracy of two - dimensional simple radiographies . there is a possibility that the delayed bleeding was caused by the plastic stents being inserted into the posterior hepatic duct . biliary metal stent insertion , mainly performed in cases of malignant biliary obstruction , has been known to cause acute or delayed hemobilia . other cases with pseudoaneurysms attributable to continuous erosion caused by biliary metal stents accompanying symptomatic hypertensive biliopathy have been reported [ 5 - 7 ] . notably though , there was one case of hemobilia which occurred during extraction of a plastic stent by endoscopy , in a patient with metastatic bile duct obstruction caused by ovarian cancer . in another case reported in the literature , hemobilia occurred 2 days after the insertion of a plastic stent via a percutaneous route , in a patient with a klatskin tumor . a third case occurred 3 weeks after stent insertion , because a long ( 15 cm ) biliary plastic stent was used to relieve obstructive jaundice caused by extrinsic compression by large pancreatic pseudocysts that continuously eroded a hepatic artery which resulted in bleeding . in our patient , so the long stent was not used ; a 10 cm straight and aother 8 cm pigtail stent were used . to our knowledge , there has been no case report of delayed severe hemobilia due to ercp - related bile duct perforation , after successful endoscopic management with biliary plastic stent insertion . transarterial embolization is the first - line treatment and the success rate is 80% to 100% , according to the most recent literature . if that procedure fails , the next step is surgery , which is rarely necessary and depends on the etiology of hemobilia . surgery involves direct exploration of the liver with hepatic resection , ligation , and/or ballooning of the bleeding vessel , aneurysm excision , cholecystectomy , and release of the bile duct obstruction . ercp has also recently played an important role in non - iatrogenic hemobilia because hepatobiliary tumors are a predominant cause of non - iatrogenic hemobilia . in summary , we report the first case of severe delayed hemobilia due to ercp - related bile duct perforation , after successful endoscopic management by stent insertion , in which bleeding occurred 10 days after stent removal and approximately 3 weeks after stent insertion . we believe that if endoscopic stent insertion is performed in cases of ercp - related bile duct perforation , stent removal may be postponed for more than 6 to 8 weeks , in order to allow for complete healing of the bile duct perforation .
hemobilia is a rare gastrointestinal bleeding , usually caused by injury to the bile duct . 
 hemobilia after endoscopic retrograde cholangiopancreatography ( ercp ) is generally self - limiting and patients will spontaneously recover , but some severe and fatal hemorrhages have been reported . 
 ercp - related bowel or bile duct perforation should be managed promptly , according to the type of injury and the status of the patient . 
 we recently experienced a case of late - onset severe hemobilia in which the patient recovered after endoscopic biliary stent insertion . 
 the problem was attributable to ercp - related bile duct perforation during stone removal , approximately 5 weeks prior to the hemorrhagic episode . 
 the removal of the stent was performed 10 days before the onset of hemobilia . 
 the bleeding was successfully treated by two sessions of transarterial coil embolization .