Endoscopic Therapy of Refractory Post-Papillotomy Bleeding With Electrocautery Forceps Coagulation Method Combined With Prophylactic Pancreatic Stenting

Introduction

The overall risk of clinically significant post-papillotomy bleeding is 1–4%, most of them manifest as a delayed hemorrhage 2–5 days after ERCP. Injection method with diluted epinephrine is the standard first line therapy of endoscopic hemostasis in these patients. In therapy resistant cases endoscopic hemocliping is effective, but optimal positioning of the hemoclips is difficult and sometimes impossible. Thermal coagulation method with coagulation forceps combined with prophylactic pancreatic duct stenting could be an alternative in these cases.

Patients and methods

We present 2 cases of recurrent post-papillotomy bleeding, both were detected in 1–6 days after the successful ERCP and EST. Standard endoscopic therapy with local injection of diluted epinephrine and/or application of hemoclips were ineffective. As a second line endoscopic therapy we used thermal coagulation of the bleeding vessels with coagulation forceps similarly to ESD. At the time of the thermal coagulation a 5F, 3–5 cm prophylactic pancreatic stent was applied to prevent pancreatitis.

Results

We achieved complete hemostasis in all patients without signs of further rebleeding or need for surgery. None of our patients developed post-procedure pancreatitis or perforation. Prophylactic pancreatic stents were safely removed after a few days.

Conclusion

We presented a new, effective and safe second line endoscopic hemostatic method in patients with therapy resistant post-papillotomy bleeding. Combination of prophylactic pancreatic stenting and thermal coagulation with coagulation forceps might be suggested as a rescue treatment in patients with severe post-papillotomy bleeding, resistant to standard endoscopic therapy.