Atlas of Gastroenterological Endoscopy
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Hemorrhage after papillotomy
Late hemorrhage after EPT - coagulum Oozing hemorrhage from roof of papilla
EPT was performed for symptomatic obstructive jaandice with a history of cholecystectomy. Severe colic developed three days after EPT and stone extraction. Endoscopic evaluation reveals a massive hemorrhage in the middle part of the duodenum. The papilla is covered by a big sentinal clot. After evacuation of the blood the bleeding site can be localized to the papilla´s roof. An active oozing hemorrhage can be seen.
visible vessel at the papilla´s roof x-ray coagulum
The hemorrhage is treated by injection of adrenalin (dilution 1:20000). The close-up reveals a big vessel above the needle- catheter. The cause of the colic attacks is identified by filling defects on radiographs, possibly representing clots in the ductular lumen.
biliary duct - lavage biliary duct - stent and control after 2 days
Biliary lavage is performed for suspected hemobilia. It produces considerable amounts of blood and blood-clots. To facilitate biliary flow a long biliary stent is deployed. A second bleeding the following day is treated by salvage fibrin injection. Complete and long lasting hemostasis is achieved by means of this compoand. The picture shows a second look two days after fibrin application. Even small papillotomies carry the risk of a late hemorrhage, especially if the roof of the papilla habours an arterial vessel, like it is shown by the example.