Massive Hemorrhage After Biliary Sphincterotomy Treated with Self-Expanding Metal Stent

CASE REPORT

Final Diagnosis

Massive hemorrhage after biliary sphincterotomy, successfully treated with fully covered self-expanding metal stent placement.

Patient Demographics

A 71-year-old female patient with a history of hypertension and stage 3 chronic renal disease presented with jaundice.

Clinical History

On CT and MRCP a biliary stricture at the bifurcation was found (Fig. A-C). Following endoscopic retrograde cholangiopancreatography (ERCP) and subsequent brushing, the stricture was diagnosed as adenocarcinoma. Panel D shows the stenosis. Two-seven French double pigtail plastic stents were placed across the stricture into the left intrahepatic system (Panel E). A billiary sphincterotomy was performed prior to stent placement. Three days post-discharge, the patient presented to an emergency room with melena, hypotension, and a drop in hemoglobin from 12 g/dL to 5 g/dL. She was resuscitated, transfused with two units of packed red blood cells, and transported with an helicopter to our facility for urgent ERCP.

Endoscopic Findings

During the urgent ERCP for bleeding, active hemorrhage was noted at the papilla, emanating around the two previously placed pigtail plastic stents.

Endoscopic Technique

Urgent ERCP for bleeding: After successful cannulation of the biliary tree with a balloon catheter and a 0,035 inch biliary guidewire, a fully covered self-expanding metal stent (Viabil) was advanced and deployed. The stent expanded well, achieving tamponade of the bleeding area, with no further hemorrhage observed.

Discussion

Massive post-sphincterotomy bleeding represents a catastrophic complication that is particularly challenging to manage due to the constraints of side-viewing endoscopy and potentially difficult papillary positioning (1-3). Various methods exist to achieve hemostasis, including local injection, endoscopic clips, balloon tamponade over a guidewire, thermal coagulation, topical hemostatic agents such as Purastat, and placement of a fully covered self-expanding metal stent. In this case, the rapid deployment and expansion of a fully covered self-expanding metal stent over a guidewire effectively controlled the hemorrhage through tamponade. This approach is considered among the most efficient and safest methods for immediate hemostasis in such critical situations.

Key Learning Points

1. Post-ERCP bleeding, particularly after sphincterotomy, can be life-threatening and requires prompt intervention.
2. Management of post-sphincterotomy bleeding can be challenging due to endoscopic limitations and papillary anatomy.
3. Fully covered self-expanding metal stents offer a fast, safe, and effective method for achieving hemostasis via tamponade in cases of massive post-sphincterotomy hemorrhage.
4. Recognition of predisposing factors and preparedness for potential complications are crucial in advanced endoscopic procedures.

References

1. Sethi S, Trieu H, Chen B, et al. Fully covered self-expandable metal stents for refractory postsphincterotomy bleeding. Endoscopy. 2012;44(S 02):E333-E334.
2. Barkun AN, Cotton PB, Shah RJ, et al. ERCP-related complications: The new ASGE guideline on endoscopy and complications in gastrointestinal endoscopy. Gastrointest Endosc. 2022;95(3):395-400.
3. Kim HJ, Kim MH, Lee SK, et al. Fully covered self-expandable metallic stents for bleeding from biliary sphincterotomy: Initial experience in four patients. Dig Dis Sci. 2013;58(5):1414-1418.