Delayed biliary hemorrhage following transjugular intrahepatic portosystemic shunt

A 44-year-old man was admitted with a 9-day history of hematochezia and hematemesis occurring 3 hours prior to admission. He had a 15-year history of hepatitis B–related liver cirrhosis and had undergone splenectomy 13 years earlier. On admission, laboratory testing revealed a hemoglobin level of 74 g/L. Abdominal computed tomography (CT) demonstrated esophageal varices and dilation of the portal vein. After 2 days of medical therapy, a transjugular intrahepatic portosystemic shunt (TIPS) was performed to relieve portal hypertension ([ Fig. 1 ]). On postoperative day 7, the patient developed abdominal pain and recurrent hematochezia. Gastroscopy revealed fresh blood clots at the duodenal papilla, raising suspicion of post-TIPS hemobilia. Endovascular intervention was subsequently performed, with coil embolization of the gastroduodenal artery ([ Fig. 2 ]). Fig. 1 A transjugular intrahepatic portosystemic shunt (TIPS) procedure. ( a – c ) Abdominal computed tomography showing liver cirrhosis, esophagogastric varices, and portal vein dilatation with a small mural thrombus. ( d and e ) Puncture of the left branch of the portal vein via the right hepatic vein to establish the shunt tract. Fig. 2 Angiographic embolization of the gastroduodenal artery. ( a ) Esophageal varices. ( b ) Fresh blood clots observed at the duodenal papilla. ( c and d ) Coil embolization of the gastroduodenal artery. Yellow arrows indicate the gastroduodenal artery; blue arrows indicate the proper hepatic artery; and red arrows indicate the embolization site. Five days later, the patient’s symptoms worsened. Repeat abdominal CT showed gallbladder enlargement with intraluminal hemorrhage. Percutaneous transhepatic gallbladder drainage (PTGD) was performed, yielding bloody bile, and the patient’s symptoms were temporarily relieved ([ Fig. 3 ]). Five days after PTGD, the hemoglobin level had decreased to 48 g/L. To localize the bleeding source, endoscopic retrograde cholangiopancreatography with cholangioscopy (eyeMAX, 9-Fr; Micro-Tech (Nanjing) Co., Ltd, Nanjing, China) was performed for the direct visualization of the intrahepatic bile ducts.[ 1​ ] No bleeding source was identified in the right hepatic duct; however, fresh blood clots and a definite bleeding point were observed at the entrance of the left hepatic duct. A covered metal stent was placed in the left hepatic duct to achieve compression hemostasis, and a plastic stent was inserted into the right hepatic duct for biliary drainage ([ Fig. 4 ]; [ Video 1 ]). During a 6-month follow-up period, no further episodes of abdominal pain or hematochezia were observed. This case highlights an effective endoscopic management strategy for secondary hemobilia following gastrointestinal interventional procedures. Fig. 3 PTGD. ( a and b ) Markedly enlarged gallbladder with intraluminal hemorrhage. ( c ) Percutaneous gallbladder puncture and drainage revealing hemorrhagic bile. PTGD, percutaneous transhepatic gallbladder drainage. Fig. 4 Cholangioscopy-guided management of intrahepatic biliary bleeding. Cholangioscopic examination of the intra- and extrahepatic bile ducts was performed. A narrowed orifice of the left hepatic duct was identified; under guidewire guidance, the cholangioscope was advanced, revealing an active bleeding site. A metal stent was subsequently placed to achieve hemostasis by compression. Video 1 Cholangioscopy-guided management of intrahepatic bile duct bleeding following transjugular intrahepatic portosystemic shunt. Download Video Endoscopy_UCTN_Code_CCL_1AZ_2AO Publication History Received: 21 December 2025 Accepted after revision: 08 June 2026 Article published online: 21 July 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany