PMC2901612_01
A clip was placed at the site of the sphincterotomy.
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fig1
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).
Severe bleeding from the sphincterotomy site.
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fig2
Another EGD was performed and showed a persistent and severe bleeding from the previous clip placement site (Figure 2).
After clip placement and sclerosis, a vessel behind the clip is visible (arrow).
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fig3
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).
The metallic stent is placed.
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fig4
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).
No signs of bleeding after metallic stent removal.
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fig5
No signs of bleeding were seen (Figure 5).
PMC2901612_02
A stone extraction balloon cathether was used for compression.
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fig6
Scientific Corporation, Natik USA) and then with a stone extraction balloon catheter (15 mm, Extractor XL, Boston Scientific Corporation, Natik USA) (Figure 6), the bleeding site was seen in the upper margin of the sphincterotomy (Figure 7). Several attempts at sclerosis with 1 : 10.000 epinephrine, total 20 mL, were injected without stopping the bleeding.
Severe bleeding from the upper margin of the sphincterotomy site.
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fig7
Scientific Corporation, Natik USA) and then with a stone extraction balloon catheter (15 mm, Extractor XL, Boston Scientific Corporation, Natik USA) (Figure 6), the bleeding site was seen in the upper margin of the sphincterotomy (Figure 7). Several attempts at sclerosis with 1 : 10.000 epinephrine, total 20 mL, were injected without stopping the bleeding.
Expandable covered metallic stent placement.
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fig8
Given our previous experience with a metal stent in post-sphincterotomy bleeding in an adult patient, we decided, 90 minutes into the procedure, to insert an expandable, covered metallic stent (4 cm in length and 1 cm in diameter, Wallstent, Boston Scientific Corporation, Natik USA) into the choledocho to mechanically compress the bleeding site and simultaneously drain the biliary duct (Figure 8).
The metal stent is removed with alligator-tooth forceps.
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fig9
The stent was patent and was removed with alligator-tooth forceps (Figure 9).
No signs of bleeding after stent removal.
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fig10
The cholangiogram was normal, and no signs of bleeding were seen (Figure 10).