Rupture of a pseudoaneurysm caused by endoscopic papillary large-balloon dilation

Endoscopic papillary large-balloon dilation (EPLBD) is a relatively new technology for removing large bile duct stones [1]. The efficacy and safety of EPLBD have been reported; however, severe complications occur in approximately 10 % of patients [2]. Hemorrhage is one of the most common complications, and endoscopic hemostasis is effective [3]. Herein, we present a case of rupture of a pseudoaneurysm following EPLBD.

A 71-year-old woman with recurrent bile duct stones was admitted to our institution. She had a previous history of recurrent episodes of acute pancreatitis. A large stone, 28 × 10 mm in size, was seen on computed tomography ([Fig. 1]). Contrast-enhanced computed tomography was not performed because of the patient's renal dysfunction. Endoscopic retrograde cholangiography revealed an oblong-shaped filling defect in the common bile duct ([Fig. 2 a]). EPLBD with a balloon catheter (CRE Wireguided Balloon Dilator, 15 – 18 mm; Boston Scientific, Natick, Massachusetts, USA) was performed to remove the bile duct stone ([Fig. 2 b]).

Fig. 1 Coronal computed tomographic scan shows a large (28 × 10-mm) stone (arrow) in the common bile duct of a 71-year-old woman with recurrent bile duct stones and a previous history of acute pancreatitis.

Fig. 2 Images obtained during endoscopic retrograde cholangiography. a An oblong-shaped defect is observed in the bile duct (arrow). b Endoscopic papillary large-balloon dilation is performed with a balloon that has a diameter of 18 mm.

Spurting bleeding was observed immediately after the balloon had been deflated ([Fig. 3 a]). Neither balloon oppression nor placement of a fully covered self-expandable metallic stent with a diameter of 10 mm was effective for hemostasis ([Fig. 3 b]). Emergency abdominal angiography was performed, and angiography of the gastroduodenal artery revealed a pseudoaneurysm of the gastroduodenal artery with extravasation into the duodenum ([Fig. 4 a], [Fig. 4 b]). The placement of five coils achieved complete hemostasis ([Fig. 5]). The patient was discharged on postoperative day 9 without further complications.

Fig. 3 Endoscopic images of the ampulla of Vater. a Spurting bleeding is observed after endoscopic papillary large-balloon dilation. b Continuous bleeding is observed after the insertion of a metallic stent.

Fig. 4 Angiographic images. a A pseudoaneurysm is observed (arrow). b Extravasation into the duodenum (arrowhead).

Fig. 5 Hemostasis after the placement of five coils is confirmed by celiac angiography.

To our knowledge, this is the first report of pseudoaneurysm rupture as a complication of EPLBD. Because this patient had a history of recurrent episodes of acute pancreatitis, a pseudoaneurysm was possible. However, we had no chance to notice the pseudoaneurysm because contrast-enhanced computed tomography was contraindicated owing to her renal dysfunction.

Care should be taken to evaluate patients undergoing EPLBD with contrast-enhanced computed tomography to detect any arterial abnormality.

Endoscopy_UCTN_Code_CPL_1AK_2A

• References

• 1 Ersoz G, Tekesin O, Ozutemiz AO et al. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest Endosc 2003; 57: 156-159
• 2 Park SJ, Kim JH, Hwang JC et al. Factors predictive of adverse events following endoscopic papillary large balloon dilation: results from a multicenter series. Dig Dis Sci 2013; 58: 1100-1109
• 3 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