Massive Hemorrhage After Biliary Sphincterotomy Treated with Self-Expanding Metal Stent

CASE REPORT

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES

Professor of Medicine, Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

Correspondence: Klaus Mönkemüller, MD, PhD — Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA

Abstract

Background: Post-sphincterotomy hemorrhage is a recognized complication of endoscopic retrograde cholangiopancreatography (ERCP) that can be life-threatening. Multiple hemostatic methods exist, but fully covered self-expanding metal stents (SEMS) offer a rapid and effective approach through tamponade.

Case: A 71-year-old female with a hilar biliary stricture diagnosed as adenocarcinoma underwent ERCP with biliary sphincterotomy and placement of two 7-French double pigtail plastic stents. Three days post-discharge, she presented with melena, hypotension, and hemoglobin drop from 12 to 5 g/dL. Urgent ERCP revealed active hemorrhage at the papilla. A fully covered self-expanding metal stent (Viabil) was deployed over a guidewire, achieving immediate tamponade and hemostasis.

Conclusion: Fully covered self-expanding metal stents provide a fast, safe, and effective method for controlling massive post-sphincterotomy hemorrhage through tamponade, particularly when conventional hemostatic methods may be limited by the constraints of side-viewing endoscopy.

Keywords: post-sphincterotomy hemorrhage; ERCP complications; self-expanding metal stent; biliary sphincterotomy; hemostasis; tamponade; fully covered metal stent; biliary stricture; adenocarcinoma

★ Key Clinical Takeaways

Post-ERCP bleeding, particularly after sphincterotomy, can be life-threatening and requires prompt intervention.
Management of post-sphincterotomy bleeding can be challenging due to the constraints of side-viewing endoscopy and difficult papillary positioning.
Fully covered self-expanding metal stents offer a fast, safe, and effective method for achieving hemostasis via tamponade in cases of massive post-sphincterotomy hemorrhage.
Multiple hemostatic methods exist — including injection, clips, balloon tamponade, thermal coagulation, and topical agents — but SEMS deployment over a guidewire provides rapid control in critical situations.
Recognition of predisposing factors and preparedness for potential complications are crucial in advanced endoscopic procedures.

Clinical History

A 71-year-old female patient with a history of hypertension and stage 3 chronic renal disease presented with jaundice. CT and MRCP revealed a biliary stricture at the bifurcation (Figure 1A–C). Following ERCP and subsequent brushing, the stricture was diagnosed as adenocarcinoma. Panel D shows the stenosis. Two 7-French double pigtail plastic stents were placed across the stricture into the left intrahepatic system (Panel E). A biliary sphincterotomy was performed prior to stent placement. Three days post-discharge, the patient presented to an emergency room with melena, hypotension, and a drop in hemoglobin from 12 g/dL to 5 g/dL. She was resuscitated, transfused with two units of packed red blood cells, and transported by helicopter to our facility for urgent ERCP.

Figure 1. Massive Hemorrhage After Biliary Sphincterotomy Treated with Self-Expanding Metal Stent. A–C. CT and MRCP images showing biliary stricture at the bifurcation; yellow circle highlights the lesion, yellow and green arrows indicate the stricture and biliary anatomy. D. Cholangiographic view showing the stenosis (blue arrow). E. Two 7-French double pigtail plastic stents placed across the stricture into the left intrahepatic system (blue arrow). F. Endoscopic view showing active hemorrhage at the papilla around the previously placed plastic stents. G–H. Fully covered self-expanding metal stent (Viabil) advanced and deployed over a guidewire. I. Post-deployment view confirming stent expansion and tamponade with no further hemorrhage.

Endoscopic Findings

During the urgent ERCP for bleeding, active hemorrhage was noted at the papilla, emanating around the two previously placed pigtail plastic stents.

Endoscopic Technique

Urgent ERCP for bleeding was performed. After successful cannulation of the biliary tree with a balloon catheter and a 0.035-inch biliary guidewire, a fully covered self-expanding metal stent (Viabil) was advanced and deployed. The stent expanded well, achieving tamponade of the bleeding area, with no further hemorrhage observed.

Discussion

Massive post-sphincterotomy bleeding represents a catastrophic complication that is particularly challenging to manage due to the constraints of side-viewing endoscopy and potentially difficult papillary positioning. Various methods exist to achieve hemostasis, including local injection, endoscopic clips, balloon tamponade over a guidewire, thermal coagulation, topical hemostatic agents such as Purastat, and placement of a fully covered self-expanding metal stent.

In this case, the rapid deployment and expansion of a fully covered self-expanding metal stent over a guidewire effectively controlled the hemorrhage through tamponade. This approach is considered among the most efficient and safest methods for immediate hemostasis in such critical situations.

References

Sethi S, Trieu H, Chen B, et al. Fully covered self-expandable metal stents for refractory postsphincterotomy bleeding. Endoscopy. 2012;44(S 02):E333-E334.
Barkun AN, Cotton PB, Shah RJ, et al. ERCP-related complications: The new ASGE guideline on endoscopy and complications in gastrointestinal endoscopy. Gastrointest Endosc. 2022;95(3):395-400.
Kim HJ, Kim MH, Lee SK, et al. Fully covered self-expandable metallic stents for bleeding from biliary sphincterotomy: Initial experience in four patients. Dig Dis Sci. 2013;58(5):1414-1418.

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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