Post-endoscopic biliary sphincterotomy bleeding: an interventional radiology approach

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Endoscopic retrograde cholangiopancreatography-related complications: risk stratification, prevention, and management

Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.

Biliary Self-Expandable Metal Stent Could Be Recommended as a First Treatment Modality for Immediate Refractory Post-Endoscopic Retrograde Cholangiopancreatography Bleeding

Background/Aims

Recent reports suggest that the biliary self-expandable metallic stent (SEMS) is highly effective for maintaining hemostasis when endoscopic hemostasis fails in endoscopic retrograde cholangiopancreatography (ERCP)-related bleeding. We compared whether temporary SEMS offers better efficacy than angioembolization for refractory immediate ERCP-related bleeding.

Methods

Patients who underwent SEMS placement or underwent angioembolization for bleeding control in refractory immediate ERCP-related bleeding were included in the retrospective analysis. We evaluated the hemostasis success rate, severity of bleeding, change in hemoglobin levels, amount of transfusion, and delay to the start of hemostasis.

Results

A total of 27 patients with SEMS and 13 patients who underwent angioembolization were enrolled. More transfusions were needed in the angioembolization group (1.0±1.4 units vs. 2.5±2.0 units; p=0.034). SEMS failure was successfully rescued by angioembolization. The partially covered SEMS (n=23, 85.1%) was generally used, and the median stent-indwelling time was 4 days. The mean delay to the start of angioembolization was 95.2±142.9 (range, 9–491) min.

Conclusions

Temporary SEMS had similar results to those of angioembolization (96.3% vs. 92.3%; p=0.588). Immediate SEMS insertion is considered a bridge treatment modality for immediate refractory ERCP-related bleeding. Angioembolization still has a role as rescue therapy when SEMS does not work effectively.

Use of fully covered self-expanding metal biliary stents for managing endoscopic biliary sphincterotomy related bleeding

Background and study aims  Endoscopic biliary sphincterotomy (EBS) related-bleeding is a common adverse event related to endoscopic retrograde cholangiopancreatography (ERCP). Traditionally, endoscopic modalities such as epinephrine injection, cauterization, and balloon tamponade have been used for management. Recently, use of a fully covered self-expandable metal stent (FCSEMS) to manage EBS-related bleeding has gained popularity. However, data regarding its use are limited to small case series. Therefore, we aimed to evaluate the safety and efficacy of FCSEMS placement for the treatment of EBS-related bleeding. Patients and methods  All patients referred to our center from October 2014 to November 2019 who had an FCSEMS placed for EBS-related bleeding were included. FCSEMS was placed either for primary control of bleeding or after failure of other traditional endoscopic hemostasis techniques at the discretion of the endoscopist. Data was collected regarding patient demographics, procedural characteristics, clinical and technical success rates of FCSEMS, as well as adverse events. Results  A total of 97 patients underwent placement of FCSEMS for EBS-related bleeding, of which 76.3 % had immediate bleeding and 23.7 % had delayed bleeding. Mean age was 67.2 years and 47.4 % were males. Seven patients who had immediate EBS-related bleeding at index ERCP underwent other endoscopic therapies prior to placement of FCSEMS for rebleeding. The technical success rate for FCSEMS placement was 100 % and the rebleeding rate was 6.2 %. Four patients with FCSEMS placement developed pancreatitis and four had stent migration. Conclusions  Our findings suggest that FCSEMS is a highly effective treatment modality for managing EBS-related bleeding and has an acceptable safety profile.

Intramural duodenal hematoma: clinical course and imaging findings

Background

Intramural duodenal hematoma is a rare condition. Different imaging modalities are at hand for diagnosis.

Purpose

To identify patients with intramural duodenal hematoma and report imaging findings and clinical courses.

Material and Methods

Typical imaging patterns using ultrasound, computed tomography, and magnetic resonance imaging were carried out on 10 patients.

Results

The mean patient age was 7.5 years. The average disease duration was 13 months. Clinical signs of improvement were observed within 16 days. Residues were still detectable at long-term follow-up.

Conclusion

For patients with intramural duodenal wall hematoma, diagnosis should be considered early. Typical imaging findings should be known to ensure optimal treatment.

ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, "postsurgical and traumatic causes of UGIB; endoscopy contraindicated" is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Relationship between postoperative duodenal papilla hemorrhage and primary disease in patients after therapeutic endoscopic retrograde cholangiopancreatography

AIM

To investigate the relationship between postoperative duodenal papilla hemorrhage and primary disease in patients after therapeutic endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

The clinical data of 661 patients treated by ERCP at our hospital were retrospectively analyzed. According to whether the patients had postoperative duodenal papilla hemorrhage or not, they were divided into a bleeding group and a non-bleeding group. The relationship between primary disease type and the risk of bleeding was then evaluated.

RESULTS

The overall bleeding rate was 6.1% (40/661). The percentage of patients with hypertension in the bleeding group was significantly higher than that in the non-bleeding group (P < 0.05). The proportions of patients with impacted stones in the ampulla of Vater, bile duct carcinoma, pancreatic carcinoma and duodenal papilla carcinoma were significantly higher in the bleeding group than that in the non-bleeding group (P < 0.05). The proportions of patients with common bile duct stones, acute suppurative cholangitis, acute biliary pancreatitis, and biliary cholangitis stricture in the two groups had no significant difference (P > 0.05).

CONCLUSION

The risk of duodenal papilla bleeding after therapeutic ERCP is greater in patients with impacted stones in the ampulla of Vater, bile duct carcinoma, pancreatic carcinoma and duodenal papilla carcinoma. Prevention of bleeding should be emphasized in these patients, and endoscopic hemostasis is safe and effective.

Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation results in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.