This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Moving on to bleeding, this was a case that I was involved in as a fellow, and I still kind of, it's horrifying to see this, but this was a patient who had a liver transplant and they were having some issues with, hopefully that's going to keep playing, yeah, with blood loss. And the surgeons really wanted us to do this ERCP and see if we could place a metal stent to tamponade the thing and see if there was hemobilia, kind of, if we could treat it that way. So you can see there's lots of clots in there. And so, clearly, this is something that I would not be doing in my current practice, I think, but we were able to gain cannulation, deep cannulation here, and then we do a sphincterotomy and we'll do some sweeps. The, you know, you're thinking about vascular anomalies, obviously, in this situation with a prior liver transplant as well, and so I've never quite seen bleeding like this. It's going to get worse, there it is, yeah, right? And the patient lived because, you know, we were doing this in an operating room ready to go if this had happened, so it was nice that they lived, but really be cautious in dealing with these patients, right? That can happen. So you don't want to do a sphincterotomy and sweep out blood clots necessarily, right? You can maybe get in and stealthily open up a fully covered metal stent to try to tamponade some kind of lower level bleeding, but you have to be careful with this. So incidence of ERCP-related bleeding, 0.3 to 2 percent, etiology, sphincterotomy, biliary and pancreatic duct injury, as you can see there, splenic injury, hepatic injury, et cetera, and certainly patients with prior hepatobiliary surgery are at higher risk. Classifications in the literature can be by timing. Most of these are delayed 50 to 70 percent or severity-based, and that's really kind of, when you're looking at the literature, how it really breaks down, and cotton had described as mild, moderate, and severe based on blood transfusions, so, you know, less than 3 grams per deciliter drop in hemoglobin is going to be mild, less than 4 unit blood transfusions, less than or equal to 4 unit blood transfusions, moderate, and then greater than that. Severe, ASCE guideline classified a bit differently with moderate requiring blood transfusion or IR intervention, and severe is a prolonged hospital stay greater than 10 days, a day in the ICU, or a surgical intervention. So there's five independent risk factors, really, when you think about post ERSP bleeding. Physician-related ones, again, related to case volume and experience. Patient-related coagulopathy, active cholangitis, and anticoagulation therapy, then 3 days after, and then procedure-related, which is occurrence of any bleeding during the procedure. This is from, actually, an article in Gut that came out in 2021, and it's ESGE and British Society of Gastroenterology that kind of put this together, looking at how you manage anticoagulation. There's an ASCE document, I think the most recent update on that was probably 2017, so it's due for something soon, I believe. But so you can see here, we have the two categories. Whenever you're looking at this, you have low-risk and high-risk patients, I'm just including high-risk here. So if you're not doing a sphincterotomy, that can be considered low-risk, and you wouldn't be doing these modifications. But this is, in my mind, kind of the best guideline right now if you're looking at how to manage these patients. And you have warfarin on the left, and you'll see there that you can hold it for five days in low-risk patients, and if it's higher-risk patients, you still do five days, but you're going to be using low-molecularly heparin. Then you have your DOACs, and these actually, it's kind of a complicated rubric, but in general, you take the last dose three days before the procedure. And then into your antiplatelet therapies, again, you have low-risk conditions and high-risk conditions, and generally these, you're looking at seven days, or you're going to have to talk to the surgeon or the cardiologist about how to best manage those patients. So more work to come on these, but it looks like we're going to be kind of learning a lot more in the near future, because this new guideline, I think, will be coming out soon. All right, so what about prevention? So blended current is definitely better than pure cutting current for sphincterotomy. Balloon sphincteroplasty might be associated with a decreased risk of bleeding. However, you have increased risk of PEP, so you have to be careful with that. Maybe a small release sphincterotomy, and that's another way to go. Injection of hypertonic saline and epinephrine proximal to the papilla has also been shown to be helpful in select patients. So management, obviously IV fluid resuscitation, treat it pretty much like a regular GI bleed, and reversal of coagulopathy when possible. Endoscopically, again, injecting Doolu epinephrine can be helpful, or spraying it. Balloon tamponade, questionable, but sometimes you can use that for certain situations. Thermal therapy certainly can be used. You want to avoid the pancreatic duct orifice in those situations. Clips, difficult to get them down. Some smaller clips are effective, but fully covered metal snets are probably the way to go for a lot of these patients. Hemostatic agents, Puristat has been used in these cases, anecdotally quite decently. You can see through it, obscure a vision like you do with other hemostatic agents. And no studies really have specifically addressed combination therapy right now.

liver transplant

ERCP

bleeding

anticoagulation therapy

metal stent