Three complications of Pair (puncture, aspiration, injection, reaspiration) in one case: Recurrent hemobilia, cyst infection and pneumonia

• Percutaneous aspiraton injection and reaspiration technique can have multiple complications like cysts infection, pneumonia and hematobilia.
• Hematobilia is a rare complication; however, early diagnosis is the key feature.
• When complicated, treatment procedure can be challenging with elonged hospital stay and multiple other investigations like ERCP.

IntroductionWith the appropriate indications, puncture, aspiration, injection and reaspiration (PAIR) is the most effective minimal invasive method used in the treatment of hydatic cysts. Hemobilia is the hemorrhagia in bile ducts in consequence of any reason. In literature there is no case with hemobilia because of PAIR. This is the first case with recurrent hemobilia, infection in cyst cavity and pneumonia because of PAIR.CaseA 66 years old female patient was admitted to hospital with complaints of abdominal pain, hematemesis and melaena. She gave the history of PAIR for two hydatic cysts. At physical examination, there were jaundice, tenderness at right subcostal area and melaena at rectal digital examination. Hemobilia was detected by abdominal ultrasonography and magnetic resonance cholangiopancreaticography (MRCP). An endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy were performed. The patient was discharged after 6 days hospital stay. One day after the discharge the patient was admitted to hospital with the same complaints again. Performing ERCP and balloon extraction, the hematoma filling the common bile duct was removed. After the patient was hemodynamically stable for 3 days, she was discharged from the hospital. A week after that the patient was admitted to hospital with the clinical findings of infected hydatic cyst and pneumonia. The patient was treated medically with mechanical ventilation support for 8 days.ConclusionIt should not be underestimated that, there can be serious complications of PAIR like hemobilia. Therefore, PAIR should be performed only in centers having appropriate medical and surgical facilities.