Therapeutic strategies for refractory variceal bleeding due to percutaneous liver biopsy: A case report

INTRODUCTION AND IMPORTANCE: Variceal bleeding due to intrahepatic arterioportal fistula is an unusual complication of percutaneous liver biopsy. As majority of variceal bleeding are cirrhotic in origin, the rare occurrence of an acquired intrahepatic arterioportal fistula presents a therapeutic dilemma. CASE PRESENTATION: We report the case of a 57-year-old female with refractory variceal bleeding that occurred six years after a percutaneous liver biopsy. As part of the workup for placement of Transjugular Intrahepatic Portosystemic Shunt, a computed tomography hepatic arteriography was performed. This revealed a large arterioportal fistula in left lobe of liver. Variceal bleeding was controlled following successful embolisation of the arterioportal fistula. CLINICAL DISCUSSION: Persistent intrahepatic arterioportal fistula can result in portal hypertension and variceal bleeding. This is a rare complication of percutaneous liver biopsy that warrants consideration as an aetiology of portal hypertension with variceal bleeding. The therapeutic strategy for refractory bleeding due to intrahepatic arterioportal fistula is different from cirrhotic portal hypertension and requires trans-arterial embolisation of the fistula. CONCLUSION: This case highlights the need to consider arterioportal fistula as an aetiology of portal hypertension as therapeutic strategy in refractory variceal bleeding is different from cirrhotic portal hypertension.