Bleeding after endoscopic sphincterotomy: Single center retrospective study

Abstract

Background and Aims: Endoscopic retrograde cholangiopancreatography is an effective diagnostic and therapeutic method; however, its invasive nature can lead to serious complications, including bleeding. The primary aim of this retrospective study, which was performed in a tertiary reference center, was to demonstrate the frequency, severity, and types of post-endoscopic sphincterotomy bleeding, identify the risk factors of post-endoscopic sphincterotomy bleeding, and determine the appropriate treatments for these patients. Material and Methods: Medical information on patients treated with endoscopic retrograde cholangiopancreatography between February 2008 and April 2013 was examined retrospectively. In this period, a total of 12,893 patients were detected; 6552 of them had no previous endoscopic retrograde cholangiopancreatography history. Patients with bleeding after endoscopic sphincterotomy were included in the study. Results: The frequency of bleeding after endoscopic sphincterotomy was 1.23% (81 patients). The mean patient age was 64.9 (18–89) years, 46 patients were women (56.8%), and 35 patients were men (43.2%). Immediate bleeding was observed in 50 (61.7%) patients, and delayed bleeding was observed in 31 (38.3%) patients. Most bleeding episodes were mild (53 patients, 65.4%), moderate

bleeding was seen in 21 patients (25.9%), and severe bleeding was seen in 7 (8.6%) patients. Epinephrine injection alone was the most frequent treatment method (41 patients, 50.6%), followed by epinephrine injection plus heater probe (25 patients, 30.8%), heater probe alone (7 patients, 8.6%), epinephrine injection plus balloon tamponade (3 patients, 3.7%), balloon tamponade alone (2 patients, 2.4%), self-expandable full covered metal stent (2 patients, 2.4%), and endoclips alone (1 patient, 1.2%). These patients did not require surgery, and mortality was not observed. Conclusion: To date, the frequency of post- endoscopic sphincterotomy bleeding is lower than reported by older studies; nonetheless, bleeding is an important complication of endoscopic retrograde cholangiopancreatography. We found a 1.23% frequency of post-endoscopic sphincterotomy bleeding, in agreement with previous literature. Our study also demonstrates the importance of early diagnosis and prompt treatment of this complication.

Keywords

• Endoscopic sphincterotomy,complication,bleeding

Endoskopik sfinkterotomi sonrası kanama: Tek merkezli retrospektif çalışma

Öz

Giriş ve Amaç: Endoskopik retrograt kolanjiyopankreatografi, pankreatobiliyer hastalıklarda etkin bir tanı ve tedavi aracı olmakla beraber ciddi komplikasyonlara sahip olan invaziv bir işlemdir. Endoskopik retrograt kolanjiyopankreatografiişleminin önemli komplikasyonlarından biri kanamadır. Retrospektif olarak tek merkezde yapılan bu çalışmanın amacı,endoskopik sfinkterotomi sonrası kanamanın sıklığını, derecesini, tipini, risk faktörlerini ve uygulanan tedavi yöntemlerini belirlemektir. Gereç ve Yöntem: Ocak 2008-Nisan 2013 tarihleri arasında merkezimizde çeşitli endikasyonlar ile endoskopik retrograt kolanjiyopankreatografi yapılan hastalara ait kayıtlar retrospektif olarak incelendi. Bu süre aralığında endoskopik retrograt kolanjiyopankreatografi yapılan toplam 12.893 hastadan endoskopik sfinkterotomi yapılan naiv papillalı 6552 hasta vardı. Endoskopik sfinkterotomi sonrası kanama gelişen hastalar çalışma popülasyonunu oluşturdu. Bulgular: Endoskopik sfinkterotomi yapılan hastaların 81’inde (%1.23) kanama saptandı. Hastaların 46’sı (%56.8) kadın ve 35’i (%43.2) erkek idi. Yaş ortalaması 64.9 (18-89) yıl olarak saptandı. Erken kanama 50 (%61.7) ve geç kanama 31 (%38.3) hastada görüldü. Kanama derecesi 53 (%65.4) hastada hafif, 21 (%25.9) hastada orta ve 7 (%8.6) hastada şiddetli saptandı. Hastaların 41’ine (%50.6) epinefrin enjeksiyonu, 25’ine (%30.8) epinefrin enjeksiyonu ile heater probu kombinasyonu, 7’sine (%8.6) heater probu, 2’sine (%2.4) balon tamponadı, 3’üne (%3.7)’üne balon tamponadı ile epinefrin enjeksiyon kombinasyonu, 2’sine (%2.4) tam kaplı metalik stent ve 1’ine (%1.2) hemoklips uygulandı. Endoskopik sfinkterotomi kanaması gelişen bu hastalarda cerrahi gereksinim ve mortalite olmadı. Sonuç: Endoskopik retrograt kolanjiyopankreatografi işleminin önemli komplikasyonlarından biri olan kanama, eski çalışmalara göre günümüzde insidansı azalmakla birlikte halen önem arzetmektedir. Çalışmamızda, son yıllarda literatürde bildirilen endoskopik sfinkterotomi sonrası kanama oranlarına benzer oranda (%1.23) saptandı. Aynı zamanda çalışmamız, endoskopik sfinkterotomi sonrası kanamalara erken tanı ve zamanında müdahalenin önemli olduğunu göstermektedir.

Anahtar Kelimeler

• Endosokopik sfinkterotomi,komplikasyon,kanama

Kaynakça

1. KAYNAKLAR 1. McCune WS, Shorb PE, Moscovitz H. Endoscopic cannulation of the ampulla of Vater: a preliminary report. Ann Surg 1968;167:752-6 2. Maple JT, Ben-Menachem T, Anderson MA, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010;71:1-9. 3. Baron TH, Mallery JS, Hirota WK, et al. The role of endoscopy in the evaluation and treatment of patients with pancreaticobiliary malignancy. Gastrointest Endosc 2003;58:643-9. 4. Costamagna G, Shah SK, Tringali A. Current management of postoperative complications and benign biliary strictures. Gastrointest Endosc Clin N Am 2003;13:635-48. 5. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-93. 6. Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007;102:1781-8. 7. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335:909-18. 8. Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001;96:417-23. 9. Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998;48:1-10. 10. Rabenstein T, Schneider HT, Hahn EG, et al. 25 years of endoscopic sphincterotomy in Erlangen: assessment of the experience in 3498 patients. Endoscopy 1998;30:A194-201. 11. Vandervoort J, Soetikno RM, Tham TC, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56:652-6. 12. Christensen M, Matzen P, Schulze S, et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60:721. 13. Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy 2007; 39:793. 14. Wang P, Li ZS, Liu F, et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 2009; 104:31. 15. Parlak E, Suna N, Kuzu UB, et al. Diverticulum With Papillae: Does Position of Papilla Affect Technical Success? Surg Laparosc Endosc Percutan Tech 2015;25:395-8. 16. Osnes M, Lotveit T, Larson S, et al. Duodenal diverticula and their relationship to age, sex, and biliary calculi. Scand J Gastroenterol 1981;16:103-7. 17. Mesh E, Friedman E, Czerniak A, et al. The association of biliary and pancreatic anomalies with periampullary duodenal diverticula. Arch Surg 1987;122:1055-7. 18. Leung JW, Chan FK, Sung JJ, et al. Endoscopic sphincterotomy-induced hemorrhage: a study of risk factors and the role of epinephrine injection. Gastrointest Endosc 1995; 42: 550-554 19. Wilcox CM, Canakis J, Mönkemüller KE, et al. Patterns of bleeding after endoscopic sphincterotomy, the subsequent risk of bleeding, and the role of epinephrine injection. Am J Gastroenterol 2004 Feb;99:244-8. 20. S. Kuran S, Parlak E, Oguz D, et al. Endoscopic sphincterotomy-induced hemorrhage: treatmen with heat probe. Gastrointest Endosc 2006;63(3):506-11. 21. Sherman S, Hawes RH, Nisi R, et al. Endoscopic sphincterotomy-induced hemorrhage: treatment with multipolar electrocoagulation. Gastrointest Endosc 1992;38:123-6. 22. Mosca S, Galasso G. Immediate and late bleeding after endoscopic sphincterotomy. Endoscopy. 1999;31:278-9. 23. Baron TH, Norton ID, Herman L. Endoscopic hemoclip placement for post-sphincterotomy bleeding. Gastrointest Endosc 2000; 52:662. 24. Katsinelos P, Paroutoglou G, Beltsis A, et al. Endoscopic hemoclip placement for postsphincterotomy bleeding refractory to injection therapy: report of two cases. Surg Laparosc Endosc Percutan Tech. 2005;15:238-40. 25. Shah JN, Marson F, Binmoeller KF. Temporary self-expandable metal stent placement for treatment of post-sphincterotomy bleeding. Gastrointest Endosc. 2010;72:1274-8.