Acute biliary-vascular fistula following needle aspiration of the liver

A patient with cavernous transformation of the portal vein and a suspected hepatic mass lesion underwent an ultrasound-guided aspiration of the liver with a skinny needle. Two days later he became acutely ill. Bilirubin level peaked at 1375 μmol/L (80.4 mg/dL), and alkaline phosphatase level was 2290 IU/mL. There was no evidence of biliary obstruction. A biliary-vascular fistula was diagnosed by endoscopic retrograde cholangiography, and nasobiliary drainage was placed, leading to resolution of the symptoms and jaundice. A pressure gradient between the biliary tree and a venous collateral probably led to flow of bile into a blood vessel. Nasobiliary drainage should be considered as a potential therapy for acute biliary-vascular fistula.