S2501 Delayed Post Sphincterotomy Bleed and Clot-Induced Cholangitis: A Rare but Life-Threatening Complication of Endoscopic Retrograde Cholangiopancreatography

Abstract

Introduction: Complication of ERCP are pancreatitis, bleeding and perforation. Post sphincterotomy (PS) bleed, which occurs in about 2% of cases, can be immediate or, very rarely, delayed. This lady had rare, but lethal complications of ERCP such as pancreatitis, severe delayed PS bleed, and clot-induced cholangitis; which was managed endoscopically. Case Description/Methods: A 28-year-old female presented with biliary type of pain abdomen, jaundice and fever. An ultrasonography showed choledocholithiasis, 15mm of size with upstream biliary dilation. Urgent ERCP was done. After biliary cannulation, when sphincterotomy was done, and pus oozed out of the ampulla, suggestive of cholangitis. As attempts to retrieve the calculi failed, mechanical lithotripsy was done and the fragments were removed with the help of basket. After complete CBD clearance, a plastic stent was deployed. There was no immediate PS bleed. But, she developed post ERCP pancreatitis and was managed conservatively. On the 5th day, she complained of melena and syncope. She also developed high-grade fever with chills. She became toxic, with tachycardia and tachypnea. Patient was shifted to ICU, and bedside endoscopy showed bleed in the periampullary area associated with large clots. The patient was intubated because of respiratory distress and started on inotropes and blood transfusion. Again, ERCP was done and blood clots were removed from the periampullary area. The old biliary stent was removed and the CBD was swiped cleared of a large clot that had adhered inside the duct and was causing cholangitis. Multiple aliquots of dilute adrenaline was injected in the peri ampullary area till hemostasis was achieved. A new plastic biliary stent was deployed in the CBD. Post the procedure, the patient began to improve clinically. Discussion: PS bleed can be immediate or very rarely delayed. According to a multivariate analysis, factors for PS bleeding includes coagulopathy, anticoagulation use, cholangitis before ERCP, bleeding during initial sphincterotomy and lower ERCP volume centre. The only risk factor in this patient was cholangitis. There are previously 5 reported cases of delayed PS bleed that has caused clot induced cholangitis. Size of calculus, prior cholangitis, and use of mechanical lithotripsy appear to be the risk factors. Recovery depends on the timing of repeat ERCP.Figure 1.: Endoscopic image showing clot post ERCP.