A case of delayed bleeding 9 days after endoscopic ultrasound-guided pancreatic pseudocyst drainage

Endoscopic ultrasound-guided pancreatic pseudocyst drainage (EUS-PPD) has become a safe and effective procedure for pancreatic pseudocysts. However, postprocedural complication rates of 8.5 % – 20 % have been reported [1] [2] [3] [4]. For delayed complications, only one case of bleeding, which occurred 23 days after EUS-PPD from the transjejunal approach, has been reported [5]. We report a case of bleeding 9 days after EUS-PPD from the transgastric approach.

A 79-year-old man was admitted to our hospital for the treatment of biliary pancreatitis. Heparin was administered because of a history of myocardial infarction. A bile duct stone was successfully removed, but pseudocyst formation occurred ([Fig. 1]). After 36 days, pseudocyst infection was suspected and EUS-PPD was performed. Heparin was stopped only on the day of the EUS-PPD procedure. Before puncturing the pseudocyst, the absence of intervening blood vessels was confirmed using the color Doppler function ([Fig. 2 a]). The pseudocyst was punctured with a 19-G needle (Sonotip; Medi-Globe GmbH, Rosenheim, Germany) under EUS guidance ([Fig. 2 b]). Then, an electrical cautery needle (Cyst-Gastro set; ENDO-FLEX GmbH, Voerde, Germany) was used to dilate the gastric and cystic wall. Finally, a 5-Fr nasocatheter was inserted into the pseudocyst.

Fig. 1 Computed tomography scan showed a 68-mm multilocular pancreatic pseudocyst (arrow) in contact with the stomach and pancreas.

Fig. 2 Puncture of the pancreatic pseudocyst. a The color Doppler function confirmed the absence of intervening blood vessels in the puncture line. b The pseudocyst was punctured with a 19-G needle under endoscopic ultrasound guidance.

There were no procedure-related adverse events and the symptoms disappeared. Although the serum hemoglobin level did not drop markedly (Day 1: 12.0 mg/dL; Day 8: 11.7 mg/dL), hematemesis was observed 9 days after EUS-PPD and the hemoglobin level dropped to 6.9 mg/dL. Emergency endoscopy showed abundant clots around the pseudocyst fistula ([Fig. 3 a, b]). Angiography showed no aneurysms or contrast medium extravasation ([Fig. 4]).

Fig. 3 Emergency endoscopy findings. a, b Abundant clots (arrow) were found around the pseudocyst fistula.

Fig. 4 Angiography showed no aneurysms or contrast medium extravasation.

The late bleeding was possibly caused by the physical stimulus from the inserted stent which caused intracystic mural vessel destruction; the antithrombotic treatment might have been a contributing factor. To our knowledge, this is the first case of delayed bleeding 9 days after EUS-PPD. Sufficient long-term care must be provided after EUS-PPD, particularly in patients receiving antithrombotic treatment.

Endoscopy_UCTN_Code_CPL_1AK_2AG

Competing interests: None

• References

• 1 Varadarajulu S, Bang JY, Phadnis MA et al. Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment in 2011 consecutive patients. J Gastrointest Surg 2011; 15: 2080-2088
• 2 Park DH, Lee SS, Moon SH et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy 2009; 41: 842-848
• 3 Künzli HT, Timmer R, Schwartz MP et al. Endoscopic ultrasonography-guided drainage is an effective and relatively safe treatment for peripancreatic fluid collections in a cohort of 108 symptomatic patients. Eur J Gastroenterol Hepatol 2013; 25: 958-963
• 4 Puri R, Mishra SR, Thandassery RB et al. Outcome and complications of endoscopic ultrasound guided pancreatic pseudocyst drainage using combined endoprosthesis and naso-cystic drain. J Gastroenterol Hepatol 2012; 27: 722-727
• 5 Itoi T, Itokawa F, Sofuni A et al. Late bleeding after EUS-guided transjejunal drainage of a pancreatic pseudocyst in a Roux-en-Y patient. Dig Endosc 2011; 23 (Suppl. 01) 51-53