Failed endoscopic ultrasound-guided gallbladder drainage due to severe bleeding immediately rescued by redo-drainage under contrast-harmonic guidance

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was first described in 2007 [1] and is considered the treatment of choice for acute cholecystitis in patients unsuitable for surgery [2] [3]. EUS-GBD was recently demonstrated to be safe and effective even in patients with cirrhosis [4] [5].

A 72-year-old man with cirrhosis was admitted to intensive care for biliary sepsis and hepatic encephalopathy. Computed tomography showed hydropic gallbladder, with thickened wall and multiple stones within the lumen. After multidisciplinary evaluation, the patient was considered unfit for surgery and EUS-GBD was undertaken ([Video 1]).

Video 1 Deployment of the distal flange of the second 8-mm lumen-apposing metal stent (LAMS) in a gallbladder lumen completely filled with fresh blood (hyperechoic material).

Upon insertion of a lumen-apposing metal stent (LAMS; Hot Axios 10 × 10 mm; Boston Scientific, Marlborough, Massachusetts, USA), torrential bleeding occurred due to inadvertent puncture of an arteriole in the gallbladder wall, as confirmed by color Doppler ([Fig. 1 a]). The gallbladder lumen quickly filled with hyperechoic material and the LAMS tip became invisible with EUS, resulting in misdeployment of the distal flange outside the gallbladder ([Fig. 1 b]). The proximal flange was not released and the stent was removed.

Fig. 1 Endoscopic ultrasound views. a Misdeployment of the lumen-apposing metal stent distal flange outside the gallbladder wall. b The gallbladder wall arteriole on color Doppler image after removal of the misdeployed stent.

A second LAMS (Hot Axios 8 × 8 mm) was inserted as close as possible to the bleeding point; after successful deployment, a large amount of fresh blood and bile drained into the stomach. Contrast-enhanced harmonic EUS (CH-EUS) identified the feeding vessel ([Fig. 2], [Fig. 3]). As no contrast spreading was seen, we hypothesized that the bleeding source was being compressed by the stent. After washing away blood clots, clear bile was observed. Nonclinically relevant hemoglobin drop was observed and biliary sepsis resolved following the procedure. Unfortunately, the patient’s condition deteriorated due to progressive renal failure and he died 25 days after admission.

Fig. 2 Fresh blood from the gallbladder lumen after deployment of a second lumen-apposing metal stent.

Fig. 3 Contrast-enhanced harmonic endoscopic ultrasound showed the gallbladder wall arteriole with no active bleeding as a result of compression by the second lumen-apposing metal stent.

Immediate LAMS replacement with its tamponade action could be an effective rescue strategy for periprocedural bleeding; color Doppler and CH-EUS were pivotal to identify the feeding vessel, guide stent deployment, and confirm final hemostasis.

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• References

• 1 Fabbri C, Luigiano C, Lisotti A. et al. Endoscopic ultrasound-guided treatments: are we getting evidence based – a systematic review. World J Gastroenterol 2014; 20: 8424-8448
• 2 Luk SW, Irani S, Krishnamoorthi R. et al. Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis. Endoscopy 2019; 51: 722-732
• 3 Teoh AY, Perez-Miranda M, Kunda R. et al. Outcomes of an international multicenter registry on EUS-guided gallbladder drainage in patients at high risk for cholecystectomy. Endosc Int Open 2019; 7: E964-E973
• 4 James TW, Krafft M, Croglio M. et al. EUS-guided gallbladder drainage in patients with cirrhosis: results of a multicenter retrospective study. Endosc Int Open 2019; 7: E1099-E1104
• 5 Fusaroli P, Serrani M, Sferrazza S. et al. Elective cholecystectomy after reversal of septic shock using multimodality endoscopic gallbladder drainage. Endoscopy 2018; 50: E299-E300