S3490 Post-ERCP Papillotomy Bleed - An Endoscopist's Worst Nightmare

Abstract

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a common therapeutic procedure to remove bile duct stones. Pancreatitis is a complication while bleeding is rare. We present a case of severe and refractory post ERCP bleed following standard papillotomy. CASE DESCRIPTION/METHODS: A 64 year old male with alcoholism presented with confusion. Vitals were normal. He had slurred speech. He was not on anticoagulation, antiplatelet agents or liver toxic drugs. Labs revealed sodium 114, INR 1.1, ALP 289, bilirubin 2.3, AST 136, ALT 98. His speech improved with sodium correction. Liver enzymes worsened, bilirubin 11.1, prompting further evaluation. HIDA showed tracer in bile duct concerning for obstruction. He did not have tenderness or fever. MRCP without obvious stones. EUS showed foci in distal CBD suggestive of small stones/sludge. During ERCP, major papilla was stenotic. Standard papillotomy performed using ERBE. Using balloon, stones removed from bile duct and plastic stent placed. The next day, Hg fell and there was melena requiring transfusion. EGD revealed post papillotomy bleed controlled with epinephrine, clips and hemospray. Patient did well for 24 hours however, Hg dropped requiring more transfusions concerning for recurrent arterial bleed. Repeat ERCP showed bleed at papillotomy site. Plastic stent removed and covered metal stent placed into bile duct to tamponade. However, there was persistent ooze of blood treated with epinephrine, clips and hemospray. Patient did well for two days and again Hg dropped with melena. Hepatobiliary surgery and IR were consulted. Patient underwent embolization of branch of GDA and hemostasis secured. Repeat endoscopy revealed no further bleed, stent removed, patient discharged home. DISCUSSION: Post-ERCP bleeding is clinically significant or insignificant. Patient risk factors are coagulopathy, high bilirubin, cirrhosis, or papillary stenosis. Technique factors are rapid cutting, papillotomy length, or papillectomy. Operator factors are inexperienced endoscopist. Bleeding often stops spontaneously, rarely life threatening and managed with endoscopic therapy. Our patient had papillary stenosis and bilirubin >10. He underwent standard papillotomy by an experienced endoscopist. He had a clinically significant and refractory bleed uncontrolled by endoscopic therapy requiring GDA embolization. Endoscopists should be vigilant about recurrent bleeding despite endoscopic intervention and be open to angiogram and if required hepatobiliary surgery consultation.