Gastrointestinal bleeding after endoscopic ultrasound-guided gallbladder drainage

Endoscopic ultrasound (EUS)-guided gallbladder drainage (EGBD) is gaining popularity as an option for the treatment of acute cholecystitis in patients who would be considered high risk for cholecystectomy [1]. EGBD has been shown to be associated with comparable technical and clinical success rates to percutaneous cholecystostomy, whilst carrying a 4.8 % – 22 % risk of adverse events, including pneumoperitoneum, bile leak, and stent migration [2] [3] [4] [5]. Stent-induced bleeding after EGBD is however uncommon.

A 95-year-old men on dabigatran with multiple comorbidities suffered from acute cholecystitis. As he was high risk for cholecystectomy, EGBD was performed. A lumen-apposing metal stent (LAMS; Spaxus, Taewoong Medical Corporation, South Korea) and a 3-cm double-pigtail stent were inserted for gallbladder drainage. He was scheduled for cholecystoscopy and stone removal 1 month later. On cholecystoscopy, a 2-cm gallstone was noted at Hartmann’s pouch but could not be removed, so the LAMS was left in situ as a long-term stent.

After 4 months, he was admitted with hematemesis and tarry stools; his hemoglobin had dropped to 5.9 g/dL. An urgent endoscopy was performed and it was found that his stomach was filled with blood clots ([Video 1]). The LAMS remained in situ at the inferoposterior wall of the first part of the duodenum, but it had caused erosion with ulceration and bleeding ([Fig. 1]). The stent was removed and exchanged for a double-pigtail stent to maintain drainage of the gallbladder ([Fig. 2]). Hemostatic treatment was not required. The patient’s dabigatran was stopped and was not restarted. His condition stabilized and he was discharged 6 days later.

Video 1 Endoscopy performed in a patient with gastrointestinal bleeding after endoscopic ultrasound-guided gallbladder drainage.

Fig. 1 Endoscopic image showing the lumen-apposing metal stent remaining in situ in the duodenum but having caused erosion with ulceration and bleeding.

Fig. 2 Fluoroscopic image showing the lumen-apposing metal stent exchanged with a double-pigtail plastic stent.

Stent-induced gastrointestinal bleeding has to be considered in post-EGBD patients with anemia or signs of gastrointestinal bleeding. Further studies on the safety of anticoagulant use in patients planned for long-term stenting are required.

Endoscopy_UCTN_Code_TTT_1AS_2AG

 

MissingLinkText

Competing interests

Prof. Anthony Y. B. Teoh is a consultant for Boston Scientific, Cook, Taewoong, and Microtech Medical Corporations.

• References

• 1 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: 722-773
• 2 Teoh AY, Serna C, Penas I. et al. Endoscopic ultrasound-guided gallbladder drainage reduces adverse events compared with percutaneous cholecystostomy in patients who are unfit for cholecystectomy. Endoscopy 2017; 49: 130-138
• 3 Tyberg A, Saumoy M, Sequeiros EV. et al. EUS-guided versus percutaneous gallbladder drainage: isnʼt it time to convert?. J Clin Gastroenterol 2018; 52: 79-84
• 4 Irani S, Ngamruengphong S, Teoh A. et al. Similar efficacies of endoscopic ultrasound gallbladder drainage with a lumen-apposing metal stent versus percutaneous transhepatic gallbladder drainage for acute cholecystitis. Clin Gastroenterol Hepatol 2017; 15: 738-745
• 5 Choi JH, Kim HW, Lee JC. et al. Percutaneous transhepatic versus EUS-guided gallbladder drainage for malignant cystic duct obstruction. Gastrointest Endosc 2017; 85: 357-364

Publication History

Article published online:
29 January 2020