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Successful management of portal cavernoma cholangiopathy induced CBD stricture with haemobilia using Fully Covered Self Expanding Metal Stent and somatostatin infusion
Poster Abstract

Background:A 40-year-old woman with a 15-year history of extrahepatic portal vein obstruction (EHPVO) presented with jaundice and pancreatic-type of pain. Magnetic Resonance Cholangiopancreatography(MRCP) revealed portal cavernoma, lienorenal collaterals, and multiple small choledocholithiasis. Mild acute pancreatitis was also noted.

Objectives:

  • To highlight the challenges and caution needed while attempting ERCP in patients with portal cavernoma cholangiopathy (PCC)
  • To evaluate the utility of peri-procedural somatostatin infusion in preventing haemobilia
  • To assess the role of fully covered self-expanding metal stents (FCSEMS) in managing biliary stricture with concurrent choledocholithiasis

Methods and Treatment: Endoscopic Ultrasound revealed multiple vascular channels obscuring the lower CBD. Endoscopic Retrograde Cholangiopancreatography(ERCP) done which showed filling defects and distal CBD narrowing. After small sphincterotomy no obvious bleed seen. Hence, decision taken to do balloon dilatation of papilla, however massive haemobilia occurred, necessitating urgent plastic stent placement. This stent became clogged within three days due to haemobilia. A repeat ERCP was planned with prophylactic somatostatin infusion. The stent was removed, and a 10 × 60 mm FCSEMS was placed under somatostatin cover and no repeat episode of haemobilia happened.

Outcome: Six weeks later, the FCSEMS was removed uneventfully under cover of  somatostatin infusion. No residual stones or bleeding were observed. The patient remained asymptomatic at four weeks follow-up.

Discussion: PCC poses unique therapeutic challenges due to vascular alterations around the bile duct. ERCP can be hazardous, with haemobilia being a major complication. Peri-procedural somatostatin may reduce bleeding risk. FCSEMS offers stricture dilatation, salvage bleeding, and facilitates spontaneous passage of stones.

Conclusion: In patients with PCC, ERCP should be approached with caution and planning. Somatostatin infusion and FCSEMS can enhance safety and efficacy in complex biliary interventions.