Endoscopic injection therapy for post-sphincterotomy bleeding: single injection orad to the papilla versus double injection orad to and into the papilla

We read with interest the article by Katsinelos et al. [1] on a novel double injection technique for endoscopic sphincterotomy (ES)-induced bleeding. Based on our previous study [2] of successful single injection of hypertonic saline-epinephrine (HSE) solution orad to the papilla for post-ES bleeding, they investigated the efficacy and safety of double injection of dextrose 50 % plus epinephrine (D₅₀+E) solution orad to and into the papilla. The double injection technique achieved successful hemostasis in 18 of the 19 patients with post-ES bleeding. Unfortunately, bleeding was uncontrolled in one patient with two sessions of the double injection technique, and required surgery with lethal outcome. We believe that our single injection is superior to their double injection technique.

Although most post-ES bleeding episodes are self-limited mucosal oozing of blood [3] [4], severe bleeding has occurred in about 1 % to 2 % of patients [4], and often results from a severed aberrant retroduodenal artery [5]. For the management of post-ES bleeding, endoscopic hemostatic methods, including the use of electrocoagulation, injection of epinephrine or sclerosing agents, and balloon tamponade are preferable to angiographic or surgical intervention [3] [5]. Endoscopic injection of epinephrine is the most commonly used, effective, and inexpensive method [3] [4], and does not cause significant tissue injury [6]. Because HSE solution has been widely used in Japan for arresting gastrointestinal bleeding [4] [6], we also commonly use the solution for endoscopic injection therapy.

In the arterial anatomy of the papillary area in 50 autopsy cases [7], the feeding artery entered the papillary area at a point exactly proximal to the bile duct protrusion in 28 cases, at a point proximal but slightly anterior in 15 cases, and at a point proximal but slightly posterior in 7 cases. We therefore believe that the submucosal injection of HSE solution orad to the papilla is the ideal technique to arrest post-ES bleeding, which exerts a local tamponade effect as well as localizing the epinephrine to cause vessel constriction [6].

In our previous study [2], a single injection of 1 mL of HSE solution orad to the papilla effectively arrested uncontrolled post-ES bleeding. Using the double injection technique [1], Katsinelos et al. injected 0.5 mL of D₅₀+E solution orad to and into the papilla. Although the use of high viscosity dextrose 50 %, rather than 0.9 % NaCl, prolongs submucosal swelling, and extends the tamponade and epinephrine effects [1], we suspect that the injected solution volume of 0.5 mL is small, with the result that post-ES bleeding is not effectively arrested in one session. In our cases, the injected 1 mL of HSE solution spreads gradually through the entire roof of the papilla. In the study of Katsinelos et al. [1], the total volume of D₅₀+E solution injected ranged from 3.5 mL to 14 mL (median volume 4.8 mL), which would indicate that hemostasis required several sessions.

When massive bleeding occurs during ES, the endoscopic field of view becomes obscured, and subsequent hemostatic maneuvers are technically difficult [5]. In such conditions, we easily injected the HSE solution orad to the bleeding site with a good field of view [2]. Although endoscopic skill is an important factor for arresting post-ES bleeding [2], our single injection method is technically easy, and requires less experience of the endoscopist. In the case of successful single injection orad to the papilla for post-ES bleeding, the second injection into the papilla used in the double injection technique is not required. Although further comparative studies are needed, we believe that our simplified technique is more effective than the double injection method.

Competing interests: None

References

• 1 Katsinelos P, Kountouras J, Chatzimavroudis G. et al . A novel technique of injection treatment for endoscopic sphincterotomy-induced hemorrhage.  Endoscopy. 2007;  39 631-636
• 2 Matsushita M, Hajiro K, Takakuwa H. et al . Effective hemostatic injection above the bleeding site for uncontrolled bleeding after endoscopic sphincterotomy.  Gastrointest Endosc. 2000;  51 221-223
• 3 Leung J WC, Chan F KL, Sung J JY. et al . Endoscopic sphincterotomy-induced hemorrhage: a study of risk factors and the role of epinephrine injection.  Gastrointest Endosc. 1995;  42 550-554
• 4 Vásconez C, Llach J, Bordas J M. et al . Injection treatment of hemorrhage induced endoscopic sphincterotomy.  Endoscopy. 1998;  30 37-39
• 5 Sherman S, Hawes R H, Nisi R. et al . Endoscopic sphincterotomy-induced hemorrhage: treatment with multipolar electrocoagulation.  Gastrointest Endosc. 1992;  38 123-126
• 6 Hirao M, Kobayashi T, Masuda K. et al . Endoscopic local injection of hypertonic saline-epinephrine solution to arrest hemorrhage from the upper gastrointestinal tract.  Gastrointest Endosc. 1985;  31 313-317
• 7 Matsushita M, Takakuwa H, Nishio A. Efficacy of endoscopic hemostatic injection orad to the site of post-sphincterotomy bleeding: anatomic confirmation.  Gastrointest Endosc. 2001;  53 270