An 82-year-old woman was referred for endoscopic retrograde cholangiopancreatography
(ERCP) for choledocholithiasis. After cannulation of the pancreatic duct, transpancreatic
sphincterotomy and placement of a 5-fr stent in the pancreas were performed.
A fully covered self-expandable metal stent was placed because of persistent post-biliary
sphincterotomy bleeding. The next day, the patient showed melena, hematemesis, and
decreased hemoglobin levels. A gastroscopy was performed and active oozing bleeding
from the papilla was evident. Injection therapy with epinephrine and hemoclips was
performed. A few hours later, a new episode of hematochezia occurred. Repeat endoscopy
showed persistent active bleeding from the papilla ([Fig. 1]). Hemostatic powder (Hemospray; Cook Medical, Winston Salem, North Carolina, USA)
was used ([Fig. 2]), but the bleeding persisted 24 hours later.
Fig. 1 The papilla showed persistent active bleeding.
Fig. 2 Hemostatic powder was used for the first rebleeding.
Endoscopic ultrasound (EUS) was performed. A curvilinear array echoendoscope (GF-UCT180;
Olympus, Tokyo, Japan) that allowed color Doppler imaging was advanced to the second
portion of the duodenum to visualize the peripapillary vascular anatomy. An arterial
vessel was identified in the duodenal wall at the level of the papilla. EUS-guided
embolization was performed with a 0.018” coil (Tornado; Cook Medical, Inc., Bloomington,
Indiana, USA) through a 22-gauge needle. Color Doppler imaging confirmed the absence
of blood flow after therapy ([Video 1]). Duodenoscopy was performed immediately after embolization, and the absence of
bleeding was confirmed ([Fig. 3]).
Video 1 Endoscopic ultrasound identified an arterial vessel in the duodenal wall at the level
of the papilla. Endoscopic ultrasound-guided embolization was performed with a 0.018”
coil through a 22-gauge needle. The absence of blood flow in the blood vessel after
therapy was confirmed by color Doppler imaging.
Fig. 3 Duodenoscopy was performed immediately after embolization, and the absence of bleeding
was confirmed.
The efficacy of EUS-guided treatments of nonvariceal upper gastrointestinal bleeding
has been reported only in the form of small case series and case reports [1]. Fockens et al. [2] first reported on the usefulness of EUS in the diagnosis and treatment of small
abnormal vessels in patients with Dieulafoy’s lesions. Currently, series have been
described with success rates of 88 % – 100 % in the treatment of gastrointestinal
stromal tumors, Dieulafoy lesions, duodenal ulcers, pancreatic pseudoaneurysms, ulcers
related to esophageal cancer, and after Roux-in-Y gastric bypass [3]
[4]
[5]. EUS-guided injection of coils for the treatment of refractory post-ERCP bleeding
has not been reported in the literature.
In conclusion, EUS-guided injection of coils is a safe and effective alternative for
the treatment of refractory post-ERCP bleeding if other conventional techniques have
failed.
Endoscopy_UCTN_Code_CPL_1AK_2AC
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
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