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Placement of covered self-expandable metal biliary stent for the treatment of severe postsphincterotomy bleeding: outcomes of two cases.

Di Pisa M, Tarantino I, Barresi L, Cintorino D, Traina M - Gastroenterol Res Pract (2010)

Bottom Line: The bleeding was stopped.In the following days, both patients remained hemodynamically stable with no further episodes of bleeding.We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

View Article: PubMed Central - PubMed

Affiliation: Gastroenterology Service, IsMeTT, UPMC, Via Tricomi 1, 90146 Palermo, Italy.

ABSTRACT
We report two cases of severe postsphincterotomy bleeding in an adult and a pediatric patient treated, as first options, with available techniques to induce hemostasis without success. Because of persisting bleeding, an expandable, partially covered, metallic stent was placed into the choledocho to mechanically compress the bleeding site. The bleeding was stopped. In the following days, both patients remained hemodynamically stable with no further episodes of bleeding. We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

No MeSH data available.


A clip was placed at the site of the sphincterotomy.
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Related In: Results  -  Collection


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fig1: A clip was placed at the site of the sphincterotomy.

Mentions: A 52-year-old man underwent laparoscopic cholecystectomy in 2002. Since then, the patient has had recurrent episodes of abdominal pain and fever. An ERCP was performed in 2004, with sphincterotomy and sludge removal. Another episode of cholangitis led to an additional procedure, performed in March 2005, with pneumatic and mechanical dilation of the sphincterotomy and sludge removal. The patient has since experienced other episodes of cholangitis, treated with antibiotic therapy only, the last one in July 2006, with evidence of cholestasis and choledochus dilation at sonography. For this reason, the patient was admitted to our institute to undergo ERCP. The patient was in good general condition, and physical examination was unremarkable. Laboratory data were Hb 15.3 gr/dL, HCT 44%, direct bilirubin 0.68 mg% gammaglutamyl transferase 281 U/L, AST/ALT 42/186 U/L, and alkaline phosphates 146 U/L. We found no comorbidities. On piperacillin/tazobactam, the patient underwent ERCP, showing mild dilation of the choledochus with several filling defects. The sphincterotomy was enlarged with a sphincterotome on a guide wire (endocut: watt 120; coag: watt 40, PSD 60 Olympus) and biliary sludge was removed with a Fogarty balloon catheter. The procedure was well tolerated and no signs of bleeding were detected. Almost 6 hours after the procedure, the patient had an episode of rectal bleeding. Blood tests showed Hb 13.3 gr/dL, HCT 39.3%, 120/80 mmHg, and heart rate 70/min. As a result, an emergency esophageal gastroduodenoscopy (EGD) was performed. It showed active bleeding from the site of previous sphincterotomy. Adrenaline was injected (1 : 10.000 dilution, 10 mL) and a metallic clip (Resolution Clip, Boston Scientific Corporation, Natik USA) was placed, with an evident cessation of hemorrhaging (Figure 1). The following day, the patient had two episodes of severe rectal bleeding. Hemoglobin levels were stable at 11.7 gr/dL, Hct 35%, arterial blood pressure was 120/70 mmHg, and heart rate was 70/min. Another EGD was performed and showed a persistent and severe bleeding from the previous clip placement site (Figure 2). Sclerosis with adrenaline (1 : 10.000 dilution, 10 mL) was redone, and a plastic stent (10 Fr, 5 cm, OASIS, Wilson Cook Medical, Winston-Salem, NC) was placed, with subsequent cessation of the bleeding. Almost 3 hours after the sclerotherapy, the patient became hemodynamically instable, hypotensive, and tachicardic, with drop in hemoglobin level (Hb: 4 gr/dL). Another episode of hematochezia occurred. EGD was repeated once more and showed a large amount of blood and clots in the stomach, and fresh bleeding from the sphincterotomy. The plastic stent was removed with a snare, and multiple clots were removed from the biliary duct with a balloon catheter, exposing a small, nonbleeding vessel in the site of the sphincterotomy (Figure 3). Severe bleeding occurred. In order to stop the bleeding, an 8 mm dilation balloon catheter (8 mm × 2 cm Hurricane Microvasive, Boston Scientific Corporation, Natik USA) was used to tampon the hemorrhage temporarily. But because of persisting of the bleeding from the sphincterotomy site when the balloon was removed, an expandable, partially covered metallic stent (4 cm in length and 1 cm in diameter, Wallstent, Boston Scientific Corporation, Natik USA) was placed in the choledocho to mechanically compress the bleeding site and drain the clots from the biliary duct (Figure 4). The patient was admitted to the intensive care unit. After volume replacement (almost 2 L) and transfusion of 4 units of packed red blood cells, the patient stabilized hemodynamically (Hb: 8 gr/dL). On postprocedure day 5, the patient was discharged home in good clinical condition. We saw him one month later in the outpatient clinic. He was in good general condition, asymptomatic, and with normal blood tests. An ERCP was scheduled to remove the previously placed metallic stent. The ERCP showed a partial obstruction in the metallic stent and was removed with a snare. The cholangiography showed multiple filling defects in the upper third of the choledocho. No signs of bleeding were seen (Figure 5). A Fogarty balloon catheter was used to remove the sludge. The patient was discharged home the day after the procedure in good general conditions, asymptomatic, and with normal blood tests. After 8 months, the patient is still asymptomatic and in good general conditions.


Placement of covered self-expandable metal biliary stent for the treatment of severe postsphincterotomy bleeding: outcomes of two cases.

Di Pisa M, Tarantino I, Barresi L, Cintorino D, Traina M - Gastroenterol Res Pract (2010)

A clip was placed at the site of the sphincterotomy.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2901612&req=5

fig1: A clip was placed at the site of the sphincterotomy.
Mentions: A 52-year-old man underwent laparoscopic cholecystectomy in 2002. Since then, the patient has had recurrent episodes of abdominal pain and fever. An ERCP was performed in 2004, with sphincterotomy and sludge removal. Another episode of cholangitis led to an additional procedure, performed in March 2005, with pneumatic and mechanical dilation of the sphincterotomy and sludge removal. The patient has since experienced other episodes of cholangitis, treated with antibiotic therapy only, the last one in July 2006, with evidence of cholestasis and choledochus dilation at sonography. For this reason, the patient was admitted to our institute to undergo ERCP. The patient was in good general condition, and physical examination was unremarkable. Laboratory data were Hb 15.3 gr/dL, HCT 44%, direct bilirubin 0.68 mg% gammaglutamyl transferase 281 U/L, AST/ALT 42/186 U/L, and alkaline phosphates 146 U/L. We found no comorbidities. On piperacillin/tazobactam, the patient underwent ERCP, showing mild dilation of the choledochus with several filling defects. The sphincterotomy was enlarged with a sphincterotome on a guide wire (endocut: watt 120; coag: watt 40, PSD 60 Olympus) and biliary sludge was removed with a Fogarty balloon catheter. The procedure was well tolerated and no signs of bleeding were detected. Almost 6 hours after the procedure, the patient had an episode of rectal bleeding. Blood tests showed Hb 13.3 gr/dL, HCT 39.3%, 120/80 mmHg, and heart rate 70/min. As a result, an emergency esophageal gastroduodenoscopy (EGD) was performed. It showed active bleeding from the site of previous sphincterotomy. Adrenaline was injected (1 : 10.000 dilution, 10 mL) and a metallic clip (Resolution Clip, Boston Scientific Corporation, Natik USA) was placed, with an evident cessation of hemorrhaging (Figure 1). The following day, the patient had two episodes of severe rectal bleeding. Hemoglobin levels were stable at 11.7 gr/dL, Hct 35%, arterial blood pressure was 120/70 mmHg, and heart rate was 70/min. Another EGD was performed and showed a persistent and severe bleeding from the previous clip placement site (Figure 2). Sclerosis with adrenaline (1 : 10.000 dilution, 10 mL) was redone, and a plastic stent (10 Fr, 5 cm, OASIS, Wilson Cook Medical, Winston-Salem, NC) was placed, with subsequent cessation of the bleeding. Almost 3 hours after the sclerotherapy, the patient became hemodynamically instable, hypotensive, and tachicardic, with drop in hemoglobin level (Hb: 4 gr/dL). Another episode of hematochezia occurred. EGD was repeated once more and showed a large amount of blood and clots in the stomach, and fresh bleeding from the sphincterotomy. The plastic stent was removed with a snare, and multiple clots were removed from the biliary duct with a balloon catheter, exposing a small, nonbleeding vessel in the site of the sphincterotomy (Figure 3). Severe bleeding occurred. In order to stop the bleeding, an 8 mm dilation balloon catheter (8 mm × 2 cm Hurricane Microvasive, Boston Scientific Corporation, Natik USA) was used to tampon the hemorrhage temporarily. But because of persisting of the bleeding from the sphincterotomy site when the balloon was removed, an expandable, partially covered metallic stent (4 cm in length and 1 cm in diameter, Wallstent, Boston Scientific Corporation, Natik USA) was placed in the choledocho to mechanically compress the bleeding site and drain the clots from the biliary duct (Figure 4). The patient was admitted to the intensive care unit. After volume replacement (almost 2 L) and transfusion of 4 units of packed red blood cells, the patient stabilized hemodynamically (Hb: 8 gr/dL). On postprocedure day 5, the patient was discharged home in good clinical condition. We saw him one month later in the outpatient clinic. He was in good general condition, asymptomatic, and with normal blood tests. An ERCP was scheduled to remove the previously placed metallic stent. The ERCP showed a partial obstruction in the metallic stent and was removed with a snare. The cholangiography showed multiple filling defects in the upper third of the choledocho. No signs of bleeding were seen (Figure 5). A Fogarty balloon catheter was used to remove the sludge. The patient was discharged home the day after the procedure in good general conditions, asymptomatic, and with normal blood tests. After 8 months, the patient is still asymptomatic and in good general conditions.

Bottom Line: The bleeding was stopped.In the following days, both patients remained hemodynamically stable with no further episodes of bleeding.We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

View Article: PubMed Central - PubMed

Affiliation: Gastroenterology Service, IsMeTT, UPMC, Via Tricomi 1, 90146 Palermo, Italy.

ABSTRACT
We report two cases of severe postsphincterotomy bleeding in an adult and a pediatric patient treated, as first options, with available techniques to induce hemostasis without success. Because of persisting bleeding, an expandable, partially covered, metallic stent was placed into the choledocho to mechanically compress the bleeding site. The bleeding was stopped. In the following days, both patients remained hemodynamically stable with no further episodes of bleeding. We believe that the application of a covered metallic stent in a severe postendoscopic-sphincterotomy bleeding, refractory to injection therapy, should be considered to avoid additional interventions, which carry a higher risk of complications, even in pediatric patients.

No MeSH data available.