Use of a gastroscope armed with a transparent cap in the treatment of bleeding after endoscopic sphincterotomy

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Cap-assisted endoscopy is useful in improving the visualization of some areas of the gastrointestinal tract [1]. A few reports exist on the use of a cap attached to the tip of a front-viewing gastroscope to facilitate the endoscopic view of the papilla of Vater. We describe the use of cap-assisted endoscopy to achieve hemostasis of an ampullary vessel bleeding after endoscopic sphincterotomy.

A 20-year-old female inpatient underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy without immediate complications for choledocholithiasis; 48 hours later she developed upper gastrointestinal bleeding. She presented with bright red hematemesis, tachycardia, hypotension, and weakness. Her hemoglobin dropped to 7 g/dL (from 13.8 g/dL at baseline).

An urgent upper endoscopy using a front-view endoscope showed no source of bleeding from esophagus and stomach, but active duodenal bleeding. Because the bleeding site was suspected to be at the sphincterotomy and a lateral-view endoscope was not available, we decided to load the endoscope with a transparent straight cap from a six-shooter multiband variceal ligator (Wilson–Cook Medical, Inc., Winston-Salem, North Carolina, USA).

We passed into the second portion of duodenum, obtaining a frontal view of the papilla of Vater and clearly identifying the bleeding point at the sphincterotomy ([Fig. 1]).

Fig. 1 Active bleeding of papilla of Vater at the edge of the sphincterotomy.

Sclerotherapy of the bleeding vessel with adrenaline 1 : 10 000 (3 mL) injected with a 25-gauge needle was successful in controlling the hemorrhage ([Fig. 2]).

Fig. 2 Successful treatment of the bleeding with an adrenaline injection.

An adequate and stable position was obtained with the transparent cap against the papilla of Vater. We verified satisfactory hemostasis and terminated the procedure ([Fig. 3]).

Fig. 3 Satisfactory hemostasis.

From the experience of this case, we believe that in situations when a lateral-view endoscope is not readily available, using a gastroscope armed with a transparent straight cap can facilitate the endoscopic view of the papilla of Vater and might also bring some cost saving benefits.

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References

• 1 Chin-Kong Y, Han-Seong N. Cap-fitted gastroscopy improves visualization and targeting of lesions.  Gastrointest Endosc. 2001;  53 93-95