Korean J Radiol.  2012 Feb;13(1):73-81. 10.3348/kjr.2012.13.1.73.

Selective Embolization for Post-Endoscopic Sphincterotomy Bleeding: Technical Aspects and Clinical Efficacy

• So YH
• Choi YH
• Chung JW
• Jae HJ
• Song SY
• Park JH

• KMID: 1058796
• DOI: http://doi.org/10.3348/kjr.2012.13.1.73

Abstract

OBJECTIVE
The objective of this study was to evaluate the technical aspects and clinical efficacy of selective embolization for post-endoscopic sphincterotomy bleeding.
MATERIALS AND METHODS
We reviewed the records of 10 patients (3%; M:F = 6:4; mean age, 63.3 years) that underwent selective embolization for post-endoscopic sphincterotomy bleeding among 344 patients who received arteriography for nonvariceal upper gastrointestinal bleeding from 2000 to 2009. We analyzed the endoscopic procedure, onset of bleeding, underlying clinical condition, angiographic findings, interventional procedure, and outcomes in these patients.
RESULTS
Among the 12 bleeding branches, primary success of hemostasis was achieved in 10 bleeding branches (83%). Secondary success occurred in two additional bleeding branches (100%) after repeated embolization. In 10 patients, post-endoscopic sphincterotomy bleedings were detected during the endoscopic procedure (n = 2, 20%) or later (n = 8, 80%), and the delay was from one to eight days (mean, 2.9 days; +/- 2.3). Coagulopathy was observed in three patients. Eight patients had a single bleeding branch, whereas two patients had two branches. On the selective arteriography, bleeding branches originated from the posterior pancreaticoduodenal artery (n = 8, 67%) and anterior pancreaticoduodenal artery (n = 4, 33%), respectively. Superselection was achieved in four branches and the embolization was performed with n-butyl cyanoacrylate. The eight branches were embolized by combined use of coil, n-butyl cyanoacrylate, or Gelfoam. After the last embolization, there was no rebleeding or complication related to embolization.
CONCLUSION
Selective embolization is technically feasible and an effective procedure for post-endoscopic sphincterotomy bleeding. In addition, the posterior pancreaticoduodenal artery is the main origin of the causative vessels of post-endoscopic sphincterotomy bleeding.

Keyword

Bleeding; Embolization; Pancreaticoduodenal artery; Sphincterotomy

MeSH Terms

Aged
Aged, 80 and over
Angiography, Digital Subtraction
Biliary Tract Diseases/radiography/*surgery
Cholangiopancreatography, Endoscopic Retrograde
Embolization, Therapeutic/*methods
Female
Gastrointestinal Hemorrhage/*etiology/radiography/*therapy
Humans
Male
Middle Aged
Postoperative Complications/*etiology/radiography/*therapy
Retrospective Studies
*Sphincterotomy, Endoscopic
Treatment Outcome

Figure

• 

  Fig. 1 52-year-old male was admitted for benign distal common bile duct stricture and presented with bleeding through endoscopic nasobiliary drainage (patient 8). A. Celiac arteriography shows extravasation of contrast material (black arrow) from vasa recta of anterior superior pancreaticoduodenal artery (white arrow). Endoscopic nasobiliary drainage was inserted into common bile duct through duodenum (arrowheads). B. Microcatheter was introduced into vasa recta of anterior superior pancreaticoduodenal artery, which was branch responsible for bleeding (white arrows). Tip of microcatheter was wedged into bleeding branch (arrowhead), and n-butyl cyanoacrylate mixture was injected to embolize bleeding branch.

• 

  Fig. 2 59-year-old male presented with hematemesis after common bile duct sweeping with stone basket for stone removal (patient 1). A. Selective arteriography of posterior superior pancreaticoduodenal artery shows active bleeding from single vasa recta (arrow). B. Superior mesenteric arteriography shows no further active bleeding after coil embolization covering bleeding branch orifice (arrow).

• 

  Fig. 3 66-year-old male was admitted for gallbladder cancer and presented with hematemesis and bleeding via endoscopic nasobiliary drainage (patient 10). A. CT scan shows enhancing mass lesion in confluence level of bile duct that originated from gallbladder (arrow) and upstream bile duct dilatation. B. Celiac arteriography shows extravasation of contrast material from posterior superior pancreaticoduodenal artery (arrow). Endoscopic nasobiliary drainage was inserted in common bile duct through duodenum (arrowheads). C. Selective arteriography of posterior superior pancreaticoduodenal artery shows active bleeding from vasa recta (arrow). D. Completion celiac arteriography shows no evidence of further active bleeding after embolization with Gelfoam particles. Embolization was done at just distal portion of bleeding branch with microcoil.

Reference

1. Ferreira LE, Baron TH. Post-sphincterotomy bleeding: who, what, when, and how. Am J Gastroenterol. 2007. 102:2850–2858.

2. Wilcox CM, Canakis J, Mönkemüller 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. 99:244–248.

3. Saeed M, Kadir S, Kaufman SL, Murray RR, Milligan F, Cotton PB. Bleeding following endoscopic sphincterotomy: angiographic management by transcatheter embolization. Gastrointest Endosc. 1989. 35:300–303.

4. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg. 2008. 143:457–461.

5. Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M, Hillon P, et al. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operative-risk patients. J Clin Gastroenterol. 2008. 42:361–367.

6. Aina R, Oliva VL, Therasse E, Perreault P, Bui BT, Dufresne MP, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol. 2001. 12:195–200.

7. Defreyne L, Vanlangenhove P, De Vos M, Pattyn P, Van Maele G, Decruyenaere J, et al. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology. 2001. 218:739–748.

8. Leung JW, Chan FK, Sung JJ, Chung S. Endoscopic sphincterotomy-induced hemorrhage: a study of risk factors and the role of epinephrine injection. Gastrointest Endosc. 1995. 42:550–554.

9. Costamagna G. What to do when the papilla bleeds after endoscopic sphincterotomy. Endoscopy. 1998. 30:40–42.

10. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996. 335:909–918.

11. 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. 37:383–393.

12. Sherman S, Hawes RH, Nisi R, Lehman GA. Endoscopic sphincterotomy-induced hemorrhage: treatment with multipolar electrocoagulation. Gastrointest Endosc. 1992. 38:123–126.

13. Kim KO, Kim TN, Kim SB, Lee JY. Characteristics of delayed hemorrhage after endoscopic sphincterotomy. J Gastroenterol Hepatol. 2010. 25:532–538.

14. Gholson CF, Favrot D, Vickers B, Dies D, Wilder W. Delayed hemorrhage following endoscopic retrograde sphincterotomy for choledocholithiasis. Dig Dis Sci. 1996. 41:831–834.

15. Mutignani M, Seerden T, Tringali A, Feisal D, Perri V, Familiari P, et al. Endoscopic hemostasis with fibrin glue for refractory postsphincterotomy and postpapillectomy bleeding. Gastrointest Endosc. 2010. 71:856–860.

16. Shah JN, Marson F, Binmoeller KF. Temporary self-expandable metal stent placement for treatment of post-sphincterotomy bleeding. Gastrointest Endosc. 2010. 72:1274–1278.

17. Kuran S, Parlak E, Oguz D, Cicek B, Disibeyaz S, Sahin B. Endoscopic sphincterotomy-induced hemorrhage: treatment with heat probe. Gastrointest Endosc. 2006. 63:506–511.

18. Matsushita M, Takakuwa H, Shimeno N, Uchida K, Nishio A, Okazaki K. Prophylactic injection of hypertonic saline-epinephrine oral to the papilla for prevention of postsphincterotomy bleeding. J Clin Gastroenterol. 2010. 44:e167–e170.

19. Yamaguchi H, Wakiguchi S, Murakami G, Hata F, Hirata K, Shimada K, et al. Blood supply to the duodenal papilla and the communicating artery between the anterior and posterior pancreaticoduodenal arterial arcades. J Hepatobiliary Pancreat Surg. 2001. 8:238–244.

20. Kimura W, Morikane K, Futakawa N, Shinkai H, Han I, Inoue T, et al. A new method of duodenum-preserving subtotal resection of the head of the pancreas based on the surgical anatomy. Hepatogastroenterology. 1996. 43:463–472.

21. Bertelli E, Di Gregorio F, Bertelli L, Mosca S. The arterial blood supply of the pancreas: a review. I. The superior pancreaticoduodenal and the anterior superior pancreaticoduodenal arteries. An anatomical and radiological study. Surg Radiol Anat. 1995. 17:97–106.

22. Bertelli E, Di Gregorio F, Bertelli L, Civeli L, Mosca S. The arterial blood supply of the pancreas: a review. II. The posterior superior pancreaticoduodenal artery. An anatomical and radiological study. Surg Radiol Anat. 1996. 18:1–9.

23. Hong KC, Freeny PC. Pancreaticoduodenal arcades and dorsal pancreatic artery: comparison of CT angiography with three-dimensional volume rendering, maximum intensity projection, and shaded-surface display. AJR Am J Roentgenol. 1999. 172:925–931.

24. Jae HJ, Chung JW, Jung AY, Lee W, Park JH. Transcatheter arterial embolization of nonvariceal upper gastrointestinal bleeding with N-butyl cyanoacrylate. Korean J Radiol. 2007. 8:48–56.

25. Jae HJ, Chung JW, Kim HC, So YH, Lim HG, Lee W, et al. Experimental study on acute ischemic small bowel changes induced by superselective embolization of superior mesenteric artery branches with N-butyl cyanoacrylate. J Vasc Interv Radiol. 2008. 19:755–763.