Post-sphincterotomy hemorrhage: Management and outcome

Hemorrhage due to endoscopic sphincterotomy (ES) is an important complication of therapeutic ERCP, occurring in up to 2.5% of patients. Optimal management and outcome of patients presenting with major hemorrhage have not been well defined. Aim: To determine the outcome of major hemorrhage of patients undergoing ES in a predominantly outpatient ERCP practice. Methods: Major hemorrhage was defined as presentation with hemoglobin drop and associated hematemesis, hematochezia or melena. Patients with these presentations due to ES were identified from our prospectively accrued GI Bleed Team data base from October 1988 to July 1997 during which 5958 ERCPs were performed. Clinical data was gathered from the database and the patient record. Endoscopie management comprised inspection with a duodenoscope and injection with epinephrine ± cautery (monopolar or bipolar). Results: Over a 9 year period, 26 patients experienced major post-ES hemorrhage at a median of 3 days post-ES (range 6hrs - 20d); 19 as outpatients and 7 as inpatients. Mean age was 68 yrs. (range 25-85). Patients presented with hematochezia (56%); melena (33%) and hematemesis (11%). In addition, 28% had symptoms of orthostasis and/or weakness. Ten patients (38%) had ingested aspirin or NSAIDs; 3 had thrombocytopenia and 2 had an elevated INR (2.4, 6.0). Indications for ES were: choledocholithiasis (15); malignancy (4); benign stricture (3); papillary stenosis (2); bile leak ( 1) and pancreatitis ( 1). Seven patients (27%) had a periampullary diverticulum and 2 had ampullary tumors. Needle-knife had been used in 2 patients. Two patients had minor bleeding at the time of ES: 1 received epinephrine injection (EI). Median transfusion requirement was 3 units pRBC (mean: 4.7; range: 0-17). All patients underwent initial endoscopy and therapy comprised of observation (4 patients), EI (4), and EI with cautery (18). One patient who was not a surgical candidate died after failed endoscopic therapy and angiographie embolization, (4% mortality). Four patients rebled a mean period of 4.5 days (range: 1-9d). Two patients who rebled responded to EI + bipolar cautery; 1 thrombocytopenic patient rebled 4 times, ceasing after fibrin glue injection and 1 patient rebled 3 times, requiring surgical oversewing. Median hospital stay due to the hemorrhage was 4 days (range: 2-18). Conclusions: Most patients with major hemorrhage had not experienced bleeding at the time of ES. Drugs which interfere with platelet function appear to be a contributor to bleeding. Endoscopie therapy of severe post-ES hemorrhage is highly successful.