Post-ERCP acute duodenal haemorrhage

Clinical History

Sudden onset of acute abdominal pain with impending haemodynamic shock, manifesting some hours after an unsuccessful attempt of operative endoscopic retrograde cholangiopancreatography (ERCP) in an elderly woman with recently diagnosed infiltrating gallbladder carcinoma.

Imaging Findings

The patient initially presented with clinical and laboratory evidence of obstructive jaundice. Ultrasound and CT (Fig.1) revealed intrahepatic bile ducts dilatation caused by a large, infiltrating neoplastic mass originating from the gallbladder fundus with direct liver invasion.
Operative ERCP, performed to relieve the intrahepatic biliary obstruction, was interrupted after sphincterotomy because of duodenal haemorrhage, which was treated with epinephrine injection and endoluminal clipping.
At onset of acute abdomen, emergency CT (Fig.2) was performed to immediately investigate possible complications, particularly duodenal perforation. Extraluminal air and signs of acute pancreatitis were excluded. The key CT finding was represented by active contrast extravasation in the duodenal lumen, consistent with persistently ongoing arterial haemorrhage. Endovascular therapeutic embolization of the gastroduodenal artery was successfully performed to stop the bleeding. Meanwhile percutaneous transhepatic biliary drainage (PTBD, Fig.3) was accomplished, obtaining relief of intrahepatic bile ducts obstruction with placement of two internal-external biliary drainage catheters.

Discussion

Currently indispensable in surgical practice, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool toward a primary therapeutic intervention because of the widespread availability of non-invasive imaging; it is extensively performed to treat disorders of the biliary tract, ampulla, and pancreatic system, and often obviates the need for surgery in elderly and fragile patients. However, as an invasive procedure ERCP is associated with non-negligible procedure-related morbidity and mortality (0.5-1.4% of patients), particularly in elderly patients with comorbidities and in centres with limited experience and caseloads [1, 2].
Cardiopulmonary depression represents the most common ERCP-related adverse event and is usually related to the use of sedation. More specific complications range from 5% to 40% of cases depending on the complexity of the procedure, the underlying diagnoses and presence of comorbidities. The most usual occurrences include acute pancreatitis, cholangitis, duodenal haemorrhage and duodenal perforation [2, 3].
Diagnosis and management of ERCP-induced complications should combine clinical and laboratory manifestations along with imaging appearances. CT represents the gold standard to assess type and severity of ERCP-induced complications, particularly to differentiate duodenal perforation and acute pancreatitis which have remarkably similar clinical manifestation [4-6].
Furthermore, ERCP may be sometimes complicated by acute duodenal haemorrhage, particularly after endoscopic sphincterotomy. Bleeding may be clinically suggested by melaena or haematemesis with associated decrease in haemoglobin levels. As this case demonstrates, arterial-phase CT acquisition with maximum-intensity projection (MIP) reconstructions viewed at vascular window settings may effectively show active contrast extravasation in the duodenum, indicating ongoing bleeding. Associated findings include duodenal wall thickening and hyperattenuating blood in the lumen [4-6].
The detection of active bleeding represents an indication for endoscopic, interventional or surgical treatment. Several endoscopic haemostatic methods have been proposed to stop bleeding, including epinephrine or a sclerosing agent, balloon tamponade, fibrin glue injection, hemoclip placement, electrocoagulation or temporary stent placement [7, 8]. When endoscopic procedures fail, bleeding control requires interventional radiological embolization or surgery [9].

Differential Diagnosis List

Final Diagnosis

Post-ERCP acute duodenal haemorrhage.

URL:	https://eurorad.org/case/11665
DOI:	10.1594/EURORAD/CASE.11665
ISSN:	1563-4086