Endoscopy 2018; 50(03): 287-289
DOI: 10.1055/s-0043-124178
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Intrabiliary argon plasma coagulation hemostasis by direct cholangioscopy for a tricky post-ERCP bleeding

Andrea Anderloni
1  Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
,
Francesco Auriemma
1  Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
,
Alessandro Fugazza
1  Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
,
Roberta Maselli
1  Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
,
Alessandro Repici
1  Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
2  Humanitas University, Rozzano, Milan, Italy
› Author Affiliations
Further Information

Publication History

Publication Date:
12 January 2018 (eFirst)

An 80-year-old man was admitted to the emergency department with fever, jaundice, and abdominal pain due to common bile duct (CBD) lithiasis. His past medical history revealed chronic renal failure and atrial fibrillation, which was treated with warfarin. Therapy with antibiotics and phytomenadione was promptly started, and international normalized ratio values returned to normal.

Cholangiography showed the CBD dilated up to 18 mm and multiple large stones. Sphincterotomy was performed, followed by papillary pneumatic dilation up to 15 mm and stone extraction, with no residual filling defect at cholangiography.

The following day, the patient presented signs of hypovolemic shock (hemoglobin 6 g/dL) and melena. Prompt transfusion was organized and an urgent ERCP showed oozing bleeding in the papillary region ([Fig. 1]). Diluted epinephrine was injected, but because of persistent active bleeding, a fully covered metal stent, 40 × 10 mm, was placed. Fibrin glue (Tissucol; Baxter AG, Vienna, Austria) was injected into the papillary area, resulting in complete hemostasis ([Fig. 2]).

Zoom Image
Fig. 1 Bleeding after endoscopic retrograde cholangiopancreatography was refractory to diluted epinephrine injection (guidewire cannulation).
Zoom Image
Fig. 2 Apposed fully covered metallic stent and fibrin glue injection during the first approach.

After 3 days, another episode of melena and anemia occurred. A further ERCP was performed, and showed a distally migrated biliary stent and visible oozing bleeding coming from the inside the CBD ([Fig. 3]).

Zoom Image
Fig. 3 Common bile duct bleeding source (outside view).

Direct cholangioscopy was performed using a slim gastroscope (EG530NP, 8.5 mm thin; Fujinon, Tokyo, Japan), under carbon dioxide insufflation, and showed an active bleeding vessel in the distal tract of the CBD. Argon plasma coagulation was successfully applied (setting Precise 15 – 20 W; Erbe, Tübingen, Germany) under direct visualization ([Fig. 4], [Video 1]), with no related adverse events.

Zoom Image
Fig. 4 Direct peroral cholangioscopy. a Argon plasma coagulation of visible oozing vessel. b Hemostasis.

Video 1 Argon plasma coagulation of active bleeding vessel in the distal tract of the common bile duct under direct visualization during cholangioscopy.

Georg Thieme Verlag. Please enable Java Script to watch the video.

The patient’s general condition and laboratory tests improved until discharge. There were no clinical signs of bleeding at 6-month follow-up.

This case describes the possible challenges in treating post-ERCP biliary bleeding and a new promising simple approach that should be considered as a part of the endoscopist’s armamentarium. To our knowledge this is the first described case of hemostatic APC application in CBD under direct visualization [1] [2] [3].

Endoscopy_UCTN_Code_TTT_1AR_2AK

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos