Intra-abdominal haemorrhage following an endoscopic retrograde cholangiopancreatography-related procedure: a rare complication

Endoscopic retrograde cholangiopancreatography (ERCP)-related procedures are used for the treatment of various pancreaticobiliary diseases. Bleeding is a complication of ERCP-related procedures (incidence 1.34 % ¹ ). Most bleeding is intraluminal ^{1 2} , which is readily diagnosed during the procedure, but intra-abdominal hemorrhage is extremely rare and may occur as a delayed event. Herein, we report a case of intra-abdominal hemorrhage associated with an ERCP-related procedure that was successfully treated by transcatheter arterial embolisation (TAE) ³ ( Video 1 ).

Video 1  Intra-abdominal hemorrhage following an endoscopic retrograde cholangiopancreatography procedure.

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An 80-year-old man with bile leakage was due to undergo endoscopic nasobiliary drainage (ENBD) ( Fig. 1 a ). Initially, the procedure was performed by a trainee with the patient in the prone position; however, the trainee could not reach the duodenal papilla with the endoscope under fluoroscopic guidance. An expert operator subsequently reached the duodenum with the patient in the left lateral decubitus position. An ENBD tube was placed across the bile leakage without difficulty. Around 3 hours post-procedure, the patient had severe epigastric pain and disordered consciousness, and his blood pressure was found to have decreased to 70/40 mmHg. Contrast-enhanced computed tomography (CECT) revealed intra-abdominal hemorrhage with evidence of extravasation ( Fig. 1 b ). Emergency angiography from the celiac artery demonstrated extravasation from the short gastric arteries ( Fig. 2 a ). Subsequently, TAE using gelatin sponge particles was performed to control the bleeding ( Fig. 2 b ). After 7 days, the patient had recovered fully, without experiencing any other complications. Of note, CECTs performed before this procedure had not detected an aneurysm.

Fig. 1.

 Computed tomography images in an 80-year-old man who was planned to undergo endoscopic nasobiliary drainage showing: a bile leakage (yellow circle); b 3 hours post-procedure (when the patient had developed severe epigastric pain, disordered consciousness, and a low blood pressure), intra-abdominal hemorrhage (yellow arrow) with evidence of extravasation of contrast (yellow triangle).

Fig. 2.

 Images during emergency angiography from the celiac artery showing: a extravasation from the short gastric arteries (yellow circle); b subsequent transcatheter arterial embolisation (TAE) using gelatin sponge particles to control the bleeding.

Several cases of intra-abdominal hemorrhage following esophagogastroduodenoscopy were reported in the era of rigid endoscopy ^{4 5} . We speculate that excessive tension on the gastric or duodenal wall caused by endoscope manipulation causes perigastric arterial injury. It is important to avoid excessive push manipulation during endoscopic procedures, and fluoroscopic guidance and/or a postural change for the patient may be needed. Endoscopists should be aware of this rare but serious post-procedural complication, so as to avoid any delay in its diagnosis and treatment.

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Endoscopy E-Videos is an open 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. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos