Clinical endoscopic management and outcome of post-endoscopic sphincterotomy bleeding

Abstract

Post-endoscopic sphincterotomy bleeding is a common complication of biliary sphincterotomy, and the incidence varies from 1% to 48%. It can be challenging to localize the bleeder or to administer various interventions through a side-viewing endoscope. This study aimed to evaluate the risk factors of post-endoscopic sphincterotomy bleeding and the outcome of endoscopic intervention therapies. We retrospectively reviewed the records of 513 patients who underwent biliary sphincterotomy in Mackay Memorial Hospital between 2011 and 2016. The blood biochemistry, comorbidities, indication for sphincterotomy, severity of bleeding, endoscopic features of bleeder, and type of endoscopic therapy were analyzed. Post-endoscopic sphincterotomy bleeding occurred in 65 (12.6%) patients. Forty-five patients had immediate bleeding and 20 patients had delayed bleeding. The multivariate analysis of risk factors associated with post-endoscopic sphincterotomy bleeding were liver cirrhosis (P = 0.029), end-stage renal disease (P = 0.038), previous antiplatelet drug use (P<0.001), and duodenal ulcer (P = 0.023). The complications of pancreatitis and cholangitis were higher in the bleeding group, with statistical significance. Delayed bleeding occurred within 1 to 7 days (mean, 2.5 days), and 60% (12/20) of the patients received endoscopic evaluation. In the delayed bleeding group, the successful hemostasis rate was 71.4% (5/7), and 65% (13/20) of the patients had ceased bleeding without endoscopic hemostasis therapy. Comparison of different therapeutic modalities showed that cholangitis was higher in patients who received epinephrine spray (P = 0.042) and pancreatitis was higher in patients who received epinephrine injection and electrocoagulation (P = 0.041 and P = 0.039 respectively). Clinically, post-endoscopic sphincterotomy bleeding and further endoscopic hemostasis therapy increase the complication rate of pancreatitis and cholangitis. Realizing the effectiveness of each therapeutic modalities and appropriate management of different levels bleeding are important.

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…With respect to antiplatelet agents other than aspirin, six controlled studies have become available since the publication of the British Society of Gastroenterology (BSG)/ESGE Guidelines [41, 45 -50]; five of them reported a significant association between antithrombotic agents and post-ERCP bleeding in univariate analysis [41, 45 -47, 49] but the association became nonsignificant in multivariate analysis in all but one study [49]. All studies were retrospective with no power calculation and antiplatelet agents were generally withheld before ERCP.…”

“…Finally, as cholangitis is more frequent in patients who present PSB [49], some experts suggest insertion of a nasobiliary drain following hemostasis of PSB, to prevent bile duct obstruction from intrabiliary clots. PSB refractory to conventional endoscopic hemostasis can require arterial embolization or even surgery [239].…”

Direct Oral Anticoagulants Increase Bleeding Risk After Endoscopic Sphincterotomy: A Retrospective Study

“…Various endoscopic approaches for the treatment of EST bleeding have been reported, including injection therapy with HSE [24], balloon compression [25], argon plasma coagulation [26], and hemoclip [27].…”

The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding

“…In particular, endoscopic sphincterotomy (EST) is efficient for endoscopic biliary stone removal or biliary stent insertion (2,3). However, post-EST bleeding is observed in 0.3%-12.7% of patients (4)(5)(6)(7)(8)(9). Although several endoscopic methods, such as clipping, epinephrine injection, and transcatheter arterial embolization, are useful in stopping ampullary bleeding, it is sometimes difficult to stop severe haemorrhaging (4).…”