Iatrogenic portobiliary fistula treated with covered stent following percutaneous transhepatic biliary drainage.

Key Takeaways for GI Nurses

• Percutaneous transhepatic biliary drainage (PTBD) is a reasonable alternative when ERCP fails or is not feasible, as illustrated in this case of a post-Whipple patient with symptomatic choledocholithiasis—but it carries its own distinct risk profile that nursing staff should understand when co-managing these patients.
• Vascular injury, including rare complications like portobiliary fistula (PBF), can occur during or after PTBD; nurses monitoring post-procedure patients should be alert to signs of hemobilia, unexplained hemodynamic changes, or abnormal catheter output even when initial imaging appears unremarkable.
• Diagnosis of complex complications like PBF may not be straightforward—this case required sequential imaging and repeat procedural evaluation because the catheter itself occluded the fistula initially, masking the finding on CT and portal venography. Nurses should anticipate that “normal” initial imaging doesn't always rule out a developing complication.
• A covered stent was ultimately used to treat the fistula, highlighting that endoscopy/IR teams have effective treatment options for vascular-biliary complications, but early recognition by bedside and procedural nursing staff is critical to timely intervention.

Clinical Relevance

This case report underscores an important reality for GI and endoscopy nurses: when ERCP is unsuccessful, PTBD performed by interventional radiology becomes a frequent next step, particularly in patients with altered anatomy such as this 62-year-old with a remote Whipple procedure and NASH cirrhosis. Nurses working in units that coordinate care between endoscopy and IR should understand the rationale for PTBD, its generally favorable safety profile, and the specific adverse event thresholds published by the Society of Interventional Radiology (10% major complications, 5.7% hemorrhage, 2% hemobilia, 3.3% mortality). Framing these numbers for patients and families—while emphasizing that actual complication rates are typically much lower—can help manage expectations during an already complex clinical course.

The development of an iatrogenic portobiliary fistula in this patient is a reminder that even “low-risk” percutaneous procedures can result in serious vascular-biliary complications, especially in patients with distorted anatomy or underlying liver disease. For nursing staff monitoring these patients post-procedure, this case reinforces the importance of vigilant assessment for subtle signs of bleeding, biliary leak, or hemodynamic instability, even when initial imaging is reassuring. The fact that the catheter itself occluded the fistula tract—delaying diagnosis—illustrates how catheter positioning and patency can directly affect diagnostic clarity, a detail relevant to nurses who manage drain care, document output characteristics, and communicate changes to the interventional and GI teams.

From an operational standpoint, this case highlights the value of close interdisciplinary communication between endoscopy, interventional radiology, and bedside nursing teams when a patient requires multiple procedural interventions. Nurses play a key role in tracking the sequence of imaging and interventions, recognizing when a clinical picture doesn't fully resolve with initial treatment, and advocating for repeat evaluation when something doesn't add up. This case also serves as a useful teaching example for professional development, demonstrating how rare complications can present diagnostic challenges and require a stepwise, multidisciplinary approach to resolution—ultimately treated successfully with a covered stent.

Bottom Line

For GI nurses, this case is a practical reminder that PTBD, while generally safe, can result in rare but serious vascular-biliary complications such as portobiliary fistula—particularly in patients with complex anatomy or cirrhosis—and that these complications may not be immediately apparent on initial imaging, making careful post-procedure monitoring and clear interdisciplinary communication essential to timely diagnosis and treatment.