Post written by Radhika Chavan, MD, DNB, from the Asian Institute of Gastroenterology, Hyderabad, India.

A 35-year-old man, diagnosed with acute necrotizing pancreatitis 7 weeks ago, presented with abdominal pain and fever for 2 weeks. Evaluation showed mild leukocytosis with raised amylase and lipase levels. Endoscopic ultrasound (EUS) showed large walled-off necrosis (WON) with minimal debris. For symptomatic WON, EUS-guided drainage was performed with the standard linear echoendoscope. Because of the minimal debris, the plan was to use a plastic stent for drainage. After puncturing the wall of WON with a 19-gauge needle, some echogenic turbulence was observed at the entry site, which became more obvious during the guidewire passage, suggestive of bleeding into the cavity. The track was dilated using over the guidewire cystotome, which caused intense bleeding and emanated a “fire breathing” appearance on Doppler. Because of severe bleeding from the entry site, we re-calibrated our prior decision of placing a plastic stent to a large caliber metal stent (LCMS). The track was dilated with a 6-mm balloon, which was kept inflated for a minute and reduced the intensity of bleeding because of tamponade. Finally a LCMS (16-x20-mm, Nagi Taewoong Medical, Korea) was deployed that immediately stopped the bleeding by further tamponade from stent expansion. Endoscopic view showed no active bleeding from entry site. An additional double-pigtail stent was placed through LCMS to prevent clogging by blood clots within cavity.

Adverse events associated with EUS-guided drainage of PFC are generally fewer compared to the conventional endoscopic drainage. Real-time imaging in EUS helps in identifying the safest puncture site by avoiding intervening vessels. Nevertheless, 1-2% of cases develop bleeding during EUS-guided drainage. Bleeding during EUS drainage could be because of various reasons, and one of them is entry site bleeding. Use of LCMS effectively stops the bleeding from the entry site by tamponade effect from the stent expansion.

When entry site bleeding is suspected, cautery (cystotome) should be avoided as it may exacerbate the bleeding, like in our case; the bleeding became more profound after the use of cystotome. Balloon may be preferred to dilate the track. Balloon inflation for a minute at the entry site may decrease the bleeding by tamponade effect. Metal stents are preferred over plastic stents as metal stent expansion gives better tamponade effects and stops the bleeding.

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