Successful hemostasis using a self-assembling peptide hydrogel for bleeding after endoscopic papillary large-balloon dilation

Adverse bleeding events can occur after endoscopic papillary large-balloon dilation (EPLBD) [1], though not as frequently as after endoscopic sphincterotomy. Post-EPLBD bleeding often originates from sites deeper than the bile duct orifice, such as lacerations of the bile duct wall, and the origin of bleeding may not be identified; therefore, it is often difficult to stop the bleeding. A novel self-assembling peptide hydrogel (PuraStat; 3-D Matrix, Tokyo, Japan) was recently developed as a hemostatic agent [2] [3] [4]. We present a case of hemostasis of massive post-EPLBD bleeding achieved with this hydrogel.

A 72-year-old woman developed obstructive jaundice due to bile duct stones. Endoscopic retrograde cholangiography was performed, followed by EPLBD with a 12-mm balloon catheter. However, bleeding was subsequently observed, which gradually worsened. White-light imaging and red dichromatic imaging [5] revealed that the origin of bleeding was deeper than the orifice of the duodenal papilla (within the bile duct), but the specific location could not be detected. Therefore, we decided to use the peptide hydrogel for hemostasis.

After placement of a 7-Fr double-pigtail plastic stent, a gel-filled catheter was slightly cannulated into the bile duct. Subsequently, the hydrogel was injected, and complete hemostasis was achieved and confirmed using white-light and red dichromatic imaging ([Fig. 1], [Video 1]). No adverse events, such as cholangitis or pancreatitis, were observed after the procedure.

Fig. 1 Endoscopic images. a Bleeding originating within the bile duct was observed after endoscopic papillary large-balloon dilation. b The self-assembling peptide hydrogel was injected into the bile duct with a catheter after the placement of the double-pigtail plastic stent. c Complete hemostasis was achieved with no adverse events.

Video 1 Successful hemostasis of massive bleeding after endoscopic papillary large-balloon dilation using a novel self-assembling peptide hydrogel.

Severe bleeding after EPLBD is rare; however, it is challenging to control and stop it when it originates within the bile duct. Intrabiliary injection of the novel self-assembling peptide hydrogel may facilitate hemostasis for post-EPLBD bleeding.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Shimizu S, Naitoh I, Nakazawa T. et al. Case of arterial hemorrhage after endoscopic papillary large balloon dilation for choledocholithiases using a covered self-expandable metallic stent. World J Gastroenterol 2015; 21: 5090-5095
• 2 Toyonaga H, Hayashi T, Hama K. et al. Rapid hemostasis using a self-assembling peptide matrix for midprocedural bleeding in endoscopic sphincterotomy. Endoscopy 2023; 55: E218-E219
• 3 Subramaniam S, Kandiah K, Chedgy F. et al. A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial. Endoscopy 2021; 53: 27-35
• 4 Yamamoto K, Sofuni A, Mukai S. et al. Use of a novel self-assembling hemostatic gel as a complementary therapeutic tool for endoscopic sphincterotomy-related bleeding. J Hepatobiliary Pancreat Sci 2022; 29: e81-e83
• 5 Inoue T, Ibusuki M, Kitano R. et al. Usefulness of red dichromatic imaging for post-endoscopic sphincterotomy bleeding. Endoscopy 2022; 54: E778-E779

Publication History

Article published online:
17 March 2023