Hemobilia from arteriobiliary fistula

A 59-year-old female presented to hospital with hematemesis, she had a history of autoimmune hepatitis requiring liver transplant complicated by hepatic artery thrombosis requiring vascular interventions. Post-transplant she developed intrahepatic duct ischemic strictures and underwent multiple endoscopic retrograde cholangiopancreatography (ERCP) interventions with balloon dilations and stent placements. Her biliary strictures improved and subsequently all the stents were removed. There were no immediate complications following the ERCP with no evidence of fistulous connection on fluoroscopy image(Fig. (Fig.1).1). Few months later, she presented to hospital multiple times with hematemesis and melena requiring blood transfusions. Endoscopic work up was unrevealing, pillcam deployment and antegrade double balloon enteroscopy could not identify an obvious source to explain the large GI bleeding. Eventually on one of the episodes of large volume hematemesis with hypotension requiring large volume transfusion and intubation; on upper endoscopy active hemobilia was visualized (Fig. (Fig.22)