Severe Post Endoscopic Biliary Sphinterotomy Bleeding in a Patient with Both Duodenal Diverticulum and Abnormal Vascular Anatomy

Abstract

Purpose: Post endoscopic biliary sphinterotomy bleeding is a frequent and life threatening complication associated with ERCP. Multiple risk factors have been identified. We describe a case of post endoscopic biliary sphinterotomy bleeding in a patient with both duodenal diverticulae and abnormal vascular anatomy. Methods: N/A Results: A 75 year-old with a history of CVA, COPD, and GERD presented to the hospital with intermittent abdominal pain. The patient reported subjective fevers and chills and was noted to have elevated LFTs. The patient's LFTs peaked at an AST of 494, ALT of 541, T. bili of 4.2, and alkaline phosphatase of 278. An MRCP revealed a 1 cm filling defect in the distal common bile duct (CBD) with mild extra-hepatic ductal dilatation. Additionally, multiple duodenal diverticulae were noted. An ERCP was performed given the findings on MRCP. Upon visualization of the ampulla, the anatomy of the ampulla was noted to be altered due to large diverticulae bilaterally. The ampulla was cannulated, and the subsequent cholangiogram revealed a large filling defect in the distal CBD. Initial sphincterotomy was performed with a 20 mm wire sphincterotome. Due to both the inadequacy and inability to extend the sphincterotomy, a 25 mm wire sphincterotome was used to further extend the sphincterotomy. Upon extension of the sphincterotomy, rapid arterial bleeding was noted. The endoscopic field was quickly and completely obscured with blood preventing any endoscopic intervention. The patient was emergently transferred to interventional radiology due to the profuse ongoing bleeding. Initial angiogram at the celiac axis revealed active bleeding from the gastroduodenal artery (GDA). Deep cannulation of the GDA revealed that the bleeding source was supplied by the GDA and a collateral branch. Multiple coils were placed across the extent of the GDA which resulted in hemostasis. Post embolization angiogram revealed a small collateral branch off of the hepatic artery in the region of the previously seen bleeding site. Due to the possibility that this was the collateral branch contributing to the bleeding, this was also embolized. Following angiography, the patient did not have any further bleeding. After close monitoring, the patient was discharged. An outpatient ERCP performed one month later resulted in the removal of the retained CBD stones. Conclusion: Hemorrhage is a well known complication of endoscopic biliary sphincterotomy during ERCP. Risk factors for post sphinterotomy bleeding are well described. While the presence of duodenal diverticulae is a well documented risk factor for post sphinterotomy bleeding, we present a case of severe bleeding in a patient with both duodenal diverticulae and abnormal vascular anatomy.