Post written by Matthew Eganhouse, MD, and Ajaypal Singh, MD, from the Division of Digestive Diseases, Rush University Medical Center, Chicago, Illinois, USA.

In our recently published video case, we describe, to our knowledge, the first time endoscopic hemostasis was achieved from active arterial bleeding within a walled-off necrosis (WON) cavity. Our patient, a 45-year-old woman, initially underwent EUS-guided cystgastrostomy with placement of a lumen-apposing metal stent (LAMS) for a symptomatic WON collection after an episode of acute necrotizing pancreatitis.

She presented 6 days later with hematemesis, hemodynamic instability, and associated significant hemoglobin drop. A large amount of blood was noted in the WON collection, but CT angiogram (CTA) performed twice within 24 hours did not reveal radiographically evident bleeding or a pseudoaneurysm. Given multiple potential target vessels and lack of active bleeding, empiric interventional radiology (IR)-guided embolization was infeasible.

After multidisciplinary discussion, endoscopic approach was pursued. Endoscopy revealed large amounts of red blood and clots filling the WON cavity and clogging the LAMS. No vessel or bleeding was noted near the LAMS or on the wall opposite the LAMS. After approximately 30 minutes of necrosectomy and clot removal, a vessel coursing through the WON cavity with pulsatile bleeding was discovered. This was successfully treated by ligating the vessel on either side of the actively bleeding portion using hemostatic clips followed by monopolar coagulation between the clip ligatures. The patient had no further bleeding episodes and had complete resolution of her WON cavity.

Bleeding after EUS-guided cystgastrostomy is uncommon but can be serious and usually is managed by IR-guided embolization or, less commonly, surgery. Most of the reported bleeding occurs because of a splenic artery pseudoaneurysm or injury from the LAMS to adjacent vessels. In our case, the bleeding originated from a vessel coursing through the collection but away from the LAMS.

As the bleeding was intermittent, CTA was unable to localize a pseudoaneurysm or bleeding source, making embolization challenging. This case also highlights the importance of multidisciplinary collaboration among IR, pancreaticobiliary surgery, and interventional GI teams.

Once a decision to proceed with endoscopy is made, it is important to evaluate the area of the stent to rule out bleeding from stent-induced trauma to vessels. After that, extensive necrosectomy and clot removal were performed. Once a bleeding vessel was found, intraprocedural discussion with the surgery team regarding proceeding with endoscopic therapy and placement of clips in the retroperitoneum was conducted. We also were very careful to select the clips with a metal inner flange to allow for better apposition.

IR-guided embolization continues to be the primary modality for management of bleeding in the WON cavity. However, in select cases when bleeding is not because of a splenic artery pseudoaneurysm or when CTA is negative, endoscopic hemostasis can be considered.

Some intraprocedural technical points to consider include evaluation of the LAMS site and opposite wall, careful necrosectomy and clot removal, and use of clips with inner flange for better apposition of bleeding vessels. This case also notes the importance of multidisciplinary collaboration in management of complex pancreatitis patients.

A spurting vessel in the walled-off necrosis cavity.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.