Bleeding

Abstract

Bleeding is one of the most frequent adverse events that may complicate interventional endoscopy. Specifically, the incidence of clinically significant bleeding during or after Endoscopic Retrograde CholangioPancreatography (ERCP) or Endoscopic Ultrasonography (EUS) is estimated to be less than 2%. It is related with interventions involving tissue dissection, resection or puncture, such as endoscopic sphincterotomy (ES), ampullectomy, EUS-fine needle aspiration (EUS-FNA), or EUS-guided management of peripancreatic fluid collections. Several risk factors have been identified including the presence of coagulopathy or thrombocytopenia, premature initiation of anticoagulant therapy postoperetively, acute cholangitis, and low volume operator. “Zipper cut” sphincterotomy, pure cutting current, ampullary stone impaction, periampullary diverticula, and needle-knife sphincterotomy are also related with increased bleeding risk during ERCP. Puncturing through dense vasculature and the presence of coagulopathy/thrombocytopenia are risk factors for hemorrhage related to EUS-FNA. Bleeding may occur during the procedure or later. When bleeding is noted during the intervention, specific hemostatic endoscopic techniques may be employed to provide hemostasis. If hemorrhage is manifested at a later stage, the clinical presentation is similar to upper gastrointestinal bleeding (hematemesis, melena, hypovolemic shock). Hypovolemic shock may be the only sign of extraluminal bleeding caused by EUS-FNA. The management is no different to that of upper gastrointestinal bleeding and includes resuscitation, general support (fluid replenishment, coagulopathy reversal, blood transfusions, hemodynamic support), and endoscopic, angiographic, or surgical treatment if bleeding persists.