A 72-year-old man was admitted for removal of bile duct stones. He
had undergone insertion of two 7-F double pigtail stents (Cook Medical,
Bloomingdale, Indiana, USA) 2 months earlier due to a failed stone extraction.
He was taking low-dose aspirin (100 mg/day), but had stopped this 1 week
ago. Endoscopic retrograde cholangiopancreatography (ERCP) following removal of
the biliary stents showed a round stone, approximately 1 cm in size,
above a weblike stricture in the distal common bile duct ([Fig. 1]). Sphincteroplasty was carried out to
10 mm for 60 seconds, using a balloon dilator (CRE Wireguided, Boston
Scientific International, La Garenne Colombes, France) over the guidewire ([Fig. 2]). However, the stone could not be extracted
because of the weblike stricture and continuous bleeding from the ampulla. An
epinephrine injection (1 : 10 000; 3 mL) was given
and an endoscopic nasobiliary drainage tube inserted. Six hours later, the
patient suddenly developed continuous hematemesis. His hemoglobin level fell
from 14.5 g/dL to 10.2 g/dL, with a blood pressure of
90/60 mm Hg. An emergency duodenoscopy revealed active bleeding
from the ampulla, and endoscopic hemostasis could not be achieved as the heavy
bleeding was masking the source ([Fig. 3]). A
double pigtail stent was inserted and emergency angiography carried out. This
showed multiple points of extravasation of the contrast medium from three
branches of the anterior superior pancreaticoduodenal artery ([Fig. 4]). The arteries were successfully embolized
with an infusion of butyl cyanoacrylate (Histoacryl) ([Fig. 5]).
Fig. 1 A round stone
(approximately 1 cm) above a weblike stricture in the distal common bile
duct (black arrow) seen on endoscopic retrograde cholangiopancreatography.
Fig. 2 Endoscopic retrograde
cholangiopancreatography findings of the balloon sphincteroplasty. The
large-balloon sphincteroplasty was carried out to 10 mm for 60 seconds,
using a balloon dilator over the guidewire (inset: endoscopic view).
Fig. 3 a Endoscopic view of the
ampulla following balloon sphincteroplasty and an epinephrine injection.
b Duodenoscopy showing active bleeding from the ampulla;
the bleeding focus is not evident because of the massive hemorrhage.
Fig. 4 a Angiography showing
multiple foci of extravasation of contrast medium from three branches of the
anterior superior pancreaticoduodenal artery (arrows). b
Superselective angiography view of the same lesion (arrows).
Fig. 5 Cessation of
extravasation and successful control of bleeding (arrow) after angiographic
embolization with Histoacryl.
Hemorrhage related to endoscopic balloon dilation has an incidence
of 0 % – 2.6 %, which is less
frequent than with sphincterotomy. Marked bleeding requiring surgical or
interventional therapy is extremely rare in reported studies [1]
[2]
[3].
Endoscopic balloon dilation is also the preferred strategy in patients with
coagulopathy [4]
[5]. However,
bleeding associated with large-balloon sphincteroplasty might be worsened by
rapid inflation or deflation of the balloon or frequent attempts of the
procedure. In such cases, angiographic embolization is an effective diagnostic
and therapeutic alternative.
Endoscopy_UCTN_Code_CPL_1AK_2AC
