Usefulness of red dichromatic imaging for post-endoscopic sphincterotomy bleeding

Endoscopic sphincterotomy (ES) is a crucial procedure in the treatment of biliary disease, but post-ES bleeding is an occasional adverse event [1]. Massive bleeding makes it difficult to continue the procedure, including hemostasis, because of poor visibility due to coagulum, the narrowness of the duodenum, and technical difficulty of using a side-viewing endoscope. Red dichromatic imaging, a recently developed novel image-enhanced endoscopy technology with good visualization of bleeding points and deep vessels, has been reported to be useful in various situations during upper and lower gastrointestinal endoscopy [2] [3] [4] [5]. Herein we present a case in which red dichromatic imaging was useful for hemostasis of massive post-ES bleeding.

A 75-year-old-man developed cholangitis due to bile duct stones. Endoscopic retrograde cholangiography was performed with a TJF-Q290V scope with the EVIS X1 system (Olympus Medial Systems, Tokyo, Japan). After biliary cannulation, ES was conducted with a standard sphincterotome. However, massive persistent bleeding occurred immediately. The endoscopic views of the duodenal papilla and the surroundings became red with blood, and it was impossible to identify the bleeding point clearly. The white-light imaging was therefore switched to red dichromatic imaging. The accumulated residual blood became inconspicuous, and the active blood stream and bleeding point could be visualized in darker yellow ([Fig. 1], [Video 1]). Hemostasis was achieved with a local epinephrine injection near the identified bleeding point on red dichromatic imaging. No adverse events and no re-bleeding were observed after the procedure.

Fig. 1 White-light versus red dichromatic imaging. a Clear endoscopic view could not be obtained with white-light imaging due to massive post-endoscopic sphincterotomy bleeding and hematoma. b After switching to red dichromatic imaging, the accumulated residual blood became inconspicuous, and the active blood stream (arrow) could be visualized in darker yellow, which enabled the identification of the bleeding point.

Video 1 Successful hemostasis of massive post-endoscopic sphincterotomy bleeding with red dichromatic imaging.

Red dichromatic imaging confers better visualization of bleeding points and active fresh bleeding, which appears as darker yellow in color. Moreover, pooled residual blood surrounding the active bleeding is less noticeable in red dichromatic imaging; thus, a clear field of view can be obtained compared to white-light imaging. These features can aid hemostatic procedures and in checking whether the bleeding has stopped, even with a side-viewing endoscope and when treating post-ES bleeding.

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• References

• 1 Freeman ML, Nelson DB, Sherman S. et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
• 2 Yahagi N, Fujimoto A, Horii J. et al. Dual red imaging: a novel endoscopic imaging technology visualizing thick blood vessels in the gastrointestinal wall. Endosc Int Open 2019; 7: E1632-E1635
• 3 Miyamoto S, Ohya TR, Nishi K. et al. Effectiveness of red dichromatic imaging for dissection of the submucosal layer when hematoma is encountered. Endoscopy 2021; 53: E413-E414
• 4 Saino M, Aoyama T, Fukumoto A. et al. Tracking the target in colonic diverticular bleeding using red dichromatic imaging. Endoscopy 2021; 53: E425-E426
• 5 Miyamoto S, Sugiura R, Abiko S. et al. Red dichromatic imaging helps in detecting exposed blood vessels in gastric ulcer induced by endoscopic submucosal dissection. Endoscopy 2021; 53: E403-E404