Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was first described in
2007 [1] and is considered the treatment of choice for acute cholecystitis in patients unsuitable
for surgery [2]
[3]. EUS-GBD was recently demonstrated to be safe and effective even in patients with
cirrhosis [4]
[5].
A 72-year-old man with cirrhosis was admitted to intensive care for biliary sepsis
and hepatic encephalopathy. Computed tomography showed hydropic gallbladder, with
thickened wall and multiple stones within the lumen. After multidisciplinary evaluation,
the patient was considered unfit for surgery and EUS-GBD was undertaken ([Video 1]).
Video 1 Deployment of the distal flange of the second 8-mm lumen-apposing metal stent (LAMS)
in a gallbladder lumen completely filled with fresh blood (hyperechoic material).
Upon insertion of a lumen-apposing metal stent (LAMS; Hot Axios 10 × 10 mm; Boston
Scientific, Marlborough, Massachusetts, USA), torrential bleeding occurred due to
inadvertent puncture of an arteriole in the gallbladder wall, as confirmed by color
Doppler ([Fig. 1 a]). The gallbladder lumen quickly filled with hyperechoic material and the LAMS tip
became invisible with EUS, resulting in misdeployment of the distal flange outside
the gallbladder ([Fig. 1 b]). The proximal flange was not released and the stent was removed.
Fig. 1 Endoscopic ultrasound views. a Misdeployment of the lumen-apposing metal stent distal flange outside the gallbladder
wall. b The gallbladder wall arteriole on color Doppler image after removal of the misdeployed
stent.
A second LAMS (Hot Axios 8 × 8 mm) was inserted as close as possible to the bleeding
point; after successful deployment, a large amount of fresh blood and bile drained
into the stomach. Contrast-enhanced harmonic EUS (CH-EUS) identified the feeding vessel
([Fig. 2], [Fig. 3]). As no contrast spreading was seen, we hypothesized that the bleeding source was
being compressed by the stent. After washing away blood clots, clear bile was observed.
Nonclinically relevant hemoglobin drop was observed and biliary sepsis resolved following
the procedure. Unfortunately, the patient’s condition deteriorated due to progressive
renal failure and he died 25 days after admission.
Fig. 2 Fresh blood from the gallbladder lumen after deployment of a second lumen-apposing
metal stent.
Fig. 3 Contrast-enhanced harmonic endoscopic ultrasound showed the gallbladder wall arteriole
with no active bleeding as a result of compression by the second lumen-apposing metal
stent.
Immediate LAMS replacement with its tamponade action could be an effective rescue
strategy for periprocedural bleeding; color Doppler and CH-EUS were pivotal to identify
the feeding vessel, guide stent deployment, and confirm final hemostasis.
Endoscopy_UCTN_Code_CPL_1AL_2AD
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
