Case Report: Delayed hemobilia caused by hepatic artery pseudoaneurysm with arterio-biliary fistula after liver transplantation

BackgroundHepatic artery pseudoaneurysm (HAP) is a rare but life-threatening complication following liver transplantation (LT). The formation of an arterio-biliary fistula leading to hemobilia is exceptionally uncommon, particularly when manifesting several months post-transplantation. Diagnosis and therapeutic management remain highly challenging because achieving definitive hemostasis often conflicts with the critical need to preserve graft arterial perfusion.Case presentationA 23-year-old male presented with recurrent hematemesis, hematochezia, and right upper quadrant pain 4 months after undergoing orthotopic LT for end-stage alcohol-related cirrhosis. While initial endoscopy pointed toward a duodenal bulb ulcer, a repeat endoscopic evaluation revealed fresh blood actively emerging from the major duodenal papilla, raising strong suspicion for hemobilia. Subsequent digital subtraction angiography (DSA) demonstrated a post-transplant HAP arising from the hilar hepatic arterial segment, communicating directly with the common bile duct, confirming an arterio-biliary fistula. Two sessions of transcatheter coil embolization achieved only temporary hemostasis. Following an early recurrence of bleeding, the patient underwent emergency surgery. The lesion was identified on the left hepatic artery near the porta hepatis. The surgical intervention included pseudoaneurysm resection, end-to-end hepatic artery reconstruction, and a Roux-en-Y biliary-enteric anastomosis. Despite an initially stable early postoperative course, the patient suffered a sudden circulatory collapse on postoperative day 6 and died despite aggressive resuscitation.ConclusionsHemobilia should be considered in liver transplant recipients with recurrent or unexplained gastrointestinal bleeding, particularly when blood is observed emerging from the major duodenal papilla. DSA should be performed promptly when clinical suspicion remains high, even if post-embolization CTA is inconclusive. Recurrent bleeding after embolization may indicate persistent fistulous communication and should prompt early multidisciplinary reassessment of definitive treatment options.