• anticoagulant
• delayed bleeding
• direct oral anticoagulant
• endoscopic sphincterotomy
• warfarin

• 2020-1 Japanese Gastroenterological Association
• 21K07949 JSPS KAKENHI

• Duodenal obstruction
• Gastrointestinal hemorrhage
• Hemostasis
• Pancreatic neoplasms
• Self expandable metallic stents

• Humans
• Male
• Female
• Propensity Score
• Retrospective Studies
• Sphincterotomy, Endoscopic/adverse effects
• Sphincterotomy, Endoscopic/methods
• Middle Aged
• Aged
• Postoperative Hemorrhage/prevention & control
• Postoperative Hemorrhage/etiology
• Surgical Instruments
• Time Factors
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects

• Humans
• Hemostasis, Endoscopic/methods
• Ice
• Postoperative Hemorrhage/etiology
• Postoperative Hemorrhage/therapy
• Sphincterotomy, Endoscopic/methods
• Water

• Hemostasis
• Precut fistulotomy
• TDM-621

• Endoscopic retrograde cholangiopancreatography
• Hemorrhage
• Infections
• Pancreatitis
• Perforation

• ERCP
• PuraStat
• bleeding
• endoscopic sphincterotomy
• hemostasis

• duckbill‐shaped anti‐reflux metal stent
• pancreatic cancer
• pseudoaneurysm
• self‐expandable metal stent
• transcatheter arterial embolization

• endoscopic papillary large balloon dilation
• endoscopic sphincterotomy
• fully covered self‐expandable metal stent
• hemostasis

• Bleeding
• Endoscopic hemostasis
• Endoscopic retrograde cholangiopancreatography
• Endoscopic sphincterotomy
• Hemostatic gel

Hemobilia occurs when there is a fistula between hepatic blood vessels and biliary radicles, and represents only a minority of upper gastrointestinal hemorrhages. Causes of hemobilia are varied, but liver abscess rarely causes hemobilia and only a few cases have been reported. Here, we present a case of atypical hemobilia caused by liver abscess that was successfully managed by endoscopic hepatobiliary intervention through endoscopic retrograde cholangiopancreatography (ERCP).

A 54-year-old man presented to our emergency department with a history of right upper quadrant abdominal colic and repeated fever for 6 d. Abdominal sonography and enhanced computed tomography revealed that there was an abscess in the right anterior lobe of the liver. During hospitalization, the patient developed upper gastrointestinal bleeding. Upper gastrointestinal endoscopy revealed a duodenal ulcer bleeding that was treated with three metal clamps. However, the hemodynamics was still unstable. Hence, upper gastrointestinal endoscopy was performed again and fresh blood was seen flowing from the ampulla of Vater. Selective angiography did not show any abnormality. An endoscopic nasobiliary drainage (ENBD) tube was inserted into the right anterior bile duct through ERCP, and subsequently cold saline containing (-)-noradrenaline was infused into the bile duct lumen through the ENBD tube with no episode of further bleeding.

Hemobilia should be considered in the development of liver abscess, and endoscopy is essential for diagnosis and management of some cases.

• Hemobilia
• Liver abscess
• Noradrenaline
• Endoscopic retrograde cholangiopancreatography
• Case report

Although patients with ampullary cancers frequently experience obstructive jaundice and tumor bleeding, there have been few reports on efficient management of refractory hemorrhage after conservative treatment. In this report, we describe a case of refractory bleeding from a 15‐mm ampullary adenocarcinoma. A Japanese woman in her 60s was urgently hospitalized for cholangitis, pancreatitis, and sepsis treatment. Investigation with a side‐viewing duodenoscope revealed an ulcerated ampullary adenocarcinoma. After the patient underwent anticoagulation therapy for pulmonary thromboembolism, the tumor bleeding gradually increased, resulting in severe anemia. Because the anemia did not improve with fasting or discontinuation of the anticoagulation therapy, the patient underwent repeated red blood cell transfusions. As no hemobilia was observed in the bile juice aspirated during endoscopic retrograde cholangiography, we supposed that the bleeding originated from the ulcerative cancer surface. We did not perform thermal therapy because we considered that it would worsen the bleeding. Abdominal angiography showed no pseudoaneurysms or extravasation. Ultimately, we performed transpapillary placement of a fully covered self‐expandable metallic stent (SEMS) with an anchoring double pigtail plastic stent that resulted in successful hemostasis. In this case, the mechanism of hemostasis was not presumably explained by direct compression of the bleeding point but by indirect compression. When tumor volume is small, the radial force of the SEMS may cause compression of the tumor volume, leading to shrinkage of the bleeding blood vessels. In conclusion, covered SEMS placement could be an efficient treatment for refractory ampullary cancer bleeding, even from an ulcerated cancer surface.

Endoscopic sphincterotomy (ES) is commonly performed during endoscopic retrograde cholangiopancreatography, and bleeding is a severe adverse event. PuraStat is a peptide developed as a hemostatic agent for endoscopy. We report its use as a hemostatic strategy in post-ES bleeding refractory to combined hemostasis. A patient with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography for stone removal. After the ES, severe bleeding refractory to the injection of diluted epinephrine around the bleeding source and metal stent placement occurred. Hemostasis was achieved with the application of the hemostatic gel. We reported the use of novel self-assembling hemostatic gel as an effective therapeutic tool for post-ES refractory bleeding.

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.

• Fully covered self-expandable metal stents
• Plastic stents
• Endoscopy
• Chronic pancreatitis
• Biliary stricture
• Biliary leak
• Stent migration

• Biliary Tract Surgical Procedures/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde
• Cholestasis/etiology
• Humans
• Metals
• Self Expandable Metallic Stents
• Stents
• Treatment Outcome

• Conventional hemostatic materials
• Hemorrhage
• Hemostasis
• Hemostatic materials
• High-performance hemostatic materials
• Wound healing

• Natural Sciences and Engineering Research Council of Canada

Recent reports suggest that the biliary self-expandable metallic stent (SEMS) is highly effective for maintaining hemostasis when endoscopic hemostasis fails in endoscopic retrograde cholangiopancreatography (ERCP)-related bleeding. We compared whether temporary SEMS offers better efficacy than angioembolization for refractory immediate ERCP-related bleeding.

Patients who underwent SEMS placement or underwent angioembolization for bleeding control in refractory immediate ERCP-related bleeding were included in the retrospective analysis. We evaluated the hemostasis success rate, severity of bleeding, change in hemoglobin levels, amount of transfusion, and delay to the start of hemostasis.

A total of 27 patients with SEMS and 13 patients who underwent angioembolization were enrolled. More transfusions were needed in the angioembolization group (1.0±1.4 units vs. 2.5±2.0 units; p=0.034). SEMS failure was successfully rescued by angioembolization. The partially covered SEMS (n=23, 85.1%) was generally used, and the median stent-indwelling time was 4 days. The mean delay to the start of angioembolization was 95.2±142.9 (range, 9–491) min.

Temporary SEMS had similar results to those of angioembolization (96.3% vs. 92.3%; p=0.588). Immediate SEMS insertion is considered a bridge treatment modality for immediate refractory ERCP-related bleeding. Angioembolization still has a role as rescue therapy when SEMS does not work effectively.

• Bleeding
• Embolization
• Endoscopic retrograde cholangiopancreatography
• Self-expandable metallic stent

• bilio-duodenal bleeding
• covered self-expandable metallic stent
• endoscopic retrograde cholangiopancreatography

• Cholangiopancreatography, Endoscopic Retrograde
• Hemostatics
• Humans
• Retrospective Studies
• Self Expandable Metallic Stents
• Sphincterotomy, Endoscopic/adverse effects
• Stents

We reviewed 7 patients with unsuccessful endoscopic hemostasis using covered self-expandable metal stent (CSEMS) placement for post-endoscopic sphincterotomy (ES) bleeding. ES with a medium incision was performed in 6 and with a large incision in 1 patient. All but 1 of them (86%) showed delayed bleeding, warranting second endoscopic therapies followed by CSEMS placement 1–5 days after the initial ES. Subsequent CSEMS placement did not achieve complete hemostasis in any of the patients. Lateral-side incision lines (3 or 9 o’clock) had more frequent bleeding points (71%) than oral-side incision lines (11–12 o’clock; 29%). Additional endoscopic hemostatic procedures with hemostatic forceps, hypertonic saline epinephrine, or hemoclip achieved excellent hemostasis, resulting in complete hemostasis in all patients. These experiences provide an alert: CSEMS placement is not an ultimate treatment for post-ES bleeding, despite its effectiveness. The lateral-side of the incision line, as well as the oral-most side, should be carefully examined for bleeding points, even after the CSEMS placement.

• Endoscopic
• Endoscopic retrograde cholangiopancreatography
• Endoscopic sphincterotomy
• Hemostasis
• Self-expandable metal stents

• Bleeding
• Endoscopic sphincterotomy
• Re-bleeding
• Self-expandable metallic stent

• Adverse event
• Biliary tract bleeding
• EUS-FNA
• Obstructive jaundice
• Pancreatic tumor

• Complications
• Computed tomography (CT)
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Post-ERCP haemorrhage
• Post-ERCP pancreatitis
• Post-ERCP perforation

• Biliary Tract Diseases/diagnostic imaging
• Biliary Tract Diseases/surgery
• Cholangiopancreatography, Endoscopic Retrograde
• Contrast Media
• Humans
• Pancreatic Diseases/diagnostic imaging
• Pancreatic Diseases/surgery
• Postoperative Complications/diagnostic imaging
• Risk Factors

Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

• Complication
• Indication
• Biliary endoscopic sphincterotomy
• Endoscopic retrograde cholangiopancreatography

• Antithrombotic agents
• Delayed hemorrhage
• Endoscopic sphincterotomy
• Risk factors

• endoscopic radiofrequency ablation
• ercp
• liver transplantation
• periampullary carcinoma
• self-expandable metallic stent

• Ablation Techniques/methods
• Ampulla of Vater
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Common Bile Duct Neoplasms/surgery
• Humans
• Liver Transplantation
• Male
• Middle Aged
• Self Expandable Metallic Stents

• Endoscopic Hemostasis
• Endoscopic Ultrasound
• Lower Intestinal Bleeding
• Upper Gastrointestinal Bleeding

• Biliary hemorrhage
• ENBD
• Forceps biopsy
• Hemostasis
• Plastic stent

A 78-year-old male was admitted to our hospital because of choledocholithiasis. ERC demonstrated choledocholithiases with a maximum diameter of 13 mm, and we performed endoscopic papillary large balloon dilation (EPLBD) with a size of 15 mm. Immediately following the balloon deflation, spurting hemorrhage occurred from the orifice of the duodenal papilla. Although we performed endoscopic hemostasis by compressing the bleeding point with the large balloon catheter, we could not achieve hemostasis. Therefore, we placed a 10 mm fully covered self-expandable metallic stent (SEMS) across the duodenal papilla, and the hemorrhage stopped immediately. After 1 wk of SEMS placement, duodenal endoscopy revealed ulcerative lesions in both the orifice of the duodenal papilla and the lower bile duct. A direct peroral cholangioscopy using an ultra-slim upper endoscope revealed a visible vessel with a longitudinal mucosal tear in the ulceration of the lower bile duct. We believe that the mucosal tear and subsequent ruptured vessel were caused by the EPLBD procedure.

• Endoscopic papillary large balloon dilation
• Hemorrhage
• Covered self-expandable metallic stent
• Direct peroral cholangioscopy
• Endoscopic hemostasis

• Aged
• Balloon Occlusion
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Choledocholithiasis/diagnosis
• Choledocholithiasis/therapy
• Dilatation/adverse effects
• Hemorrhage/diagnosis
• Hemorrhage/etiology
• Hemorrhage/therapy
• Hemostasis, Endoscopic
• Humans
• Male
• Metals
• Prosthesis Design
• Stents
• Time Factors
• Treatment Outcome
• Vascular System Injuries/diagnosis
• Vascular System Injuries/etiology
• Vascular System Injuries/therapy

• ERCP
• benign biliary stricture
• biliary leak
• biliary stenosis
• endoscopy
• malignant biliary stricture
• plastic stent
• self-expanding metal stent

• Clips
• Endoscopic band ligation
• Gastrointestinal bleeding
• Hemostasis
• Hemostatic spray
• Peptic ulcer bleeding
• Perforation
• Thermal coagulation

• Bleeding
• Cholangitiis
• Complications
• ERCP
• Pancreatitis
• Perforation
• Risk factors
• Sphincterotomy

• Bile Ducts
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Duodenum/injuries
• Esophageal Perforation/etiology
• Humans
• Pancreatitis/complications
• Pancreatitis/etiology
• Postoperative Hemorrhage/etiology
• Risk Factors
• Stomach/injuries

• Cryotherapy
• EUS-guided angiotherapy
• Endoscopic suturing
• Hemostasis
• Hemostatic spray
• Nonvariceal upper gastrointestinal bleeding
• Over-the-scope clip
• Radiofrequency ablation

• Endoscopic haemostasis
• Gastro-intestinal bleeding
• Gastro-intestinal haemorrhage
• Haemostatic powders
• Hemospray
• Over-the-scope clips

• Bleeding
• Diagnosis and management of severe complications
• Embolization
• GI emergencies
• GI endoscopy adverse events
• Haemorrhage
• Infection
• Perforation

• Emergencies
• Endoscopy, Gastrointestinal/adverse effects
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/surgery
• Gastrointestinal Tract/injuries
• Humans
• Wounds and Injuries/diagnosis
• Wounds and Injuries/etiology
• Wounds and Injuries/surgery

Rapid advances in the technology of gastrointestinal endoscopy as well as the evolution of science have made it necessary for us to continue update in either various endoscopic techniques or state of art lectures relevant to endoscopy. International Digestive Endoscopy Network (IDEN) 2013 was held in conjunction with Korea-Japan Joint Symposium on Gastrointestinal Endoscopy (KJSGE) during June 8 to 9, 2013 at Seoul, Korea. Two days of impressive scientific program dealt with a wide variety of basic concerns from upper gastrointestine (GI), lower GI, pancreaticobiliary endoscopy to advanced knowledge including endoscopic submucosal dissection forum. IDEN seems to be an excellent opportunity to exchange advanced information of the latest issues on endoscopy with experts from around the world. In this special issue of Clinical Endoscopy, we prepared state of art review articles from contributing authors and the current highlights will skillfully deal with very hot spots of each KJSGE, upper GI, lower GI, and pancreaticobiliary sessions by associated editors of Clinical Endoscopy.

• Clinical Endoscopy
• Highlight
• International Digestive Endoscopy Network
• Japan Gastrointestinal Endoscopy Society
• Korean Society of Gastrointestinal Endoscopy

Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS.

We report a case of an immediate internal spurting arterial bleeding precipitated during EUS-guided pseudocyst drainage which stopped instantaneously by placement of a double flanged covered self-expandable metal stent through mechanical hemostasis.

In an unusual situation of bleeding from collateral circulation near the pseudocyst wall during pseudocyst drainage, the placement of an expandable metal stent proved to be useful.