Endoluminal hemostasis of a Dieulafoy-like lesion of the gallbladder after endoscopic ultrasound-guided biliary drainage by a lumen-apposing stent

A 57-year-old woman presented to our unit for jaundice related to pancreatic cancer with a previously stented duodenal stricture. As the duodenal papilla or choledochus was not reachable, endoscopic ultrasound (EUS)-guided gallbladder biliary drainage was achieved by cholecystogastrostomy with a lumen-apposing metal stent (LAMS) (Axios 10 mm; Boston Scientific, Marlborough, Massachusetts, USA).

A few days after the procedure, jaundice worsened, and the patient lost 2 g/dL of hemoglobin. A computed tomography scan showed bleeding in the gallbladder with clots obstructing the bile ducts ([Fig. 1]). An upper gastrointestinal endoscopy was then performed ([Video 1]). Spontaneous passage into the gallbladder with a standard scope was not possible through the LAMS, and we therefore performed a 11.5 mm balloon dilation in an attempt to pass the standard scope; however, this was unsuccessful. We then used an ultrathin scope (UTS). After washing out the blood clot, an active bleed spurting from a Dieulafoy-like lesion of the gallbladder was evident ([Fig. 2]). Hemostasis was performed using argon plasma coagulation because no other endotherapy tool was usable in the tiny operating channel of the UTS ([Fig. 3]). The patient did not present any recurrence of bleeding, jaundice regressed, and she was able to resume chemotherapy ([Video 1]).

Fig. 1 Gallbladder bleeding on computed tomography scan.

Video 1 Endoluminal hemostasis of a Dieulafoy-like lesion of the gallbladder through a lumen-apposing stent.

Fig. 2 Bleeding from a Dieulafoy-like lesion of the gallbladder.

Fig. 3 Hemostasis with argon plasma coagulation.

This bleeding might be secondary to the puncture of the gallbladder by the cystotome because of its location just in front of the LAMS prosthesis.

EUS-guided gallbladder drainage is mostly used in cases of cholecystitis [1]. Biliary drainage by cholecystogastrostomy with LAMS has been described as a rescue therapy, with a clinical success of > 90 % [2]. Peroral cholecystoscopy using a UTS through a LAMS is possible and has been used for diagnosis and therapeutic purposes with targeted gallbladder biopsies or endoscopic gallstone removal [3].

The use of APC with ultraslim endoscope for peroral endoscopic hemostasis of the gallbladder is also feasible and effective.

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Competing Interest

The authors declare that they have no conflict of interest.

• References

• 1 Higa JT, Sahar N, Kozarek RA. et al. EUS-guided gallbladder drainage with a lumen-apposing metal stent versus endoscopic transpapillary gallbladder drainage for the treatment of acute cholecystitis (with videos). Gastrointest Endosc 2019; 90: 483-492
• 2 Issa D, Irani S, Law R. et al. Endoscopic ultrasound-guided gallbladder drainage as a rescue therapy for unresectable malignant biliary obstruction: a multicenter experience. Endoscopy 2020; 53: 827-831
• 3 Yoo HW, Moon JH, Lee YN. et al. Peroral cholecystoscopy using a multibending ultraslim endoscope through a lumen-apposing metal stent for endoscopic ultrasound-guided gallbladder drainage: a feasibility study. Endoscopy 2022; 54: 384-388

Publication History

Article published online:
10 October 2022