Lipiodol as a marker for hepatocellular carcinoma migrating into the bile duct.

is an effective palliative treatment for unresectable hepatocellular carcinoma (HCC). However, several complications of TACE have been reported, including transient fever and pain after the procedure, hepatic infarction, liver abscess, hepatic failure, biliary stricture, and biloma [1–3], although acute obstructive cholangitis due to migration of the necrotic tumor after TACE is very rare. We report two cases of acute cholangitis secondary to biliary migration of necrotic hepatocellular carcinoma, both of which were diagnosed preendoscopically by computed tomography (CT) scan of the abdomen. Lipiodol stain was used as a marker for necrotic tumor migration. Our first patient was a 63-year-old man who had undergone three sessions of TACE without any complications. Subsequently, a new lesion was identified adjacent to the previous lesion and a percutaneous ultrasonography-guided liver biopsy was done just before the fourth session of TACE. However, 1 day later the patient developed fever with progressive jaundice. A CT scan of abdomen showed a tiny, hyperdense spot obstructing the common bile duct (CBD). The spot was of the same density as the Lipiodol stain in the liver (●" Fig. 1). Another hyperdense spot was also detected in the intestinal lumen (●" Fig. 2a,b). Endoscopic sphincterotomy and balloon removal were carried out, and 1 month after endoscopic retrograde cholangiopancreatography (ERCP), another abdominal CT scan demonstrated disappearance of Lipiodol stain (●" Fig. 3). Our second patient, a 63-year-old man with known HCC, presented with acute cholangitis within 3 weeks of TACE. A CT scan of the abdomen showed intraluminal Lipiodol stain in the distal CBD and a small Lipiodol stain in the stomach (●" Fig. 4a,b). On day 1 after the procedure, his symptoms, including fever and abdominal pain, resolved spontaneously and subsequently serum total bilirubin also decreased. A repeat CT scan of the abdomen did not reveal any Lipiodol stain in the gastrointestinal tract.