Transjugular intrahepatic portosystemic shunt (TIPS) is a common procedure used to alleviate the secondary effects of portal hypertension including uncontrolled variceal bleeding, refractory ascites, and hepatic pleural effusion (hydrothorax). There are several well-known complications of TIPS, including portosystemic encephalopathy, hemolytic anemia, hepatic ischemia, and stent thrombosis.1 In this case report we present a rare but serious complication of TIPS – bilhemia - in which bile escapes into the bloodstream through a fistula between the biliary tree and the hepatic venous system.

Case Presentation

A 56 year-old female with cirrhosis due to chronic hepatitis C presented to the hospital for a scheduled esophagogastroduodenoscopy (EGD) for evaluation and banding of esophageal varices. During the procedure, a large varix ruptured, requiring the patient to undergo an emergent TIPS procedure to control the hemorrhage.

A TIPS was attempted using a 10mm x 10mm Viatorr covered stent. In the operative report, the interventional radiologist noted that multiple unsuccessful attempts were made accessing the right portal vein, requiring repeated repositioning of the cannula. Ultimately, a successful bridge was created between the right hepatic vein and central portal vein, which reduced the portosystemic gradient from 14 mmHg to 3 mmHg. The patient was stabilized hemodynamically with a transfusion of seven units of packed red blood cells and was admitted to the medical intensive care unit (MICU).

Three days following the procedure the patient became jaundiced. Her laboratory profile at that time showed that her total and direct bilirubin levels had increased almost 10-fold, while her transaminases and INR remained stable (Table 1). An abdominal ultrasound was performed to evaluate the stent, which was found to be patent. There was also no evidence of biliary obstruction/dilatation on ultrasound. Over the course of her hospital stay, the patient’s bilirubin continued to rise (Figure 1) while her alkaline phosphatase, transaminases, and INR remained stable (Figures 2-3). The continual rise in bilirubin prompted an abdominal CT, which showed a patent TIPS and no evidence of hepatic ischemia or biliary duct dilatation.