Retrospective Cohort Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 21, 2016; 22(11): 3196-3201
Published online Mar 21, 2016. doi: 10.3748/wjg.v22.i11.3196
Predictors of re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy bleeding
Mu-Hsien Lee, Yung-Kuan Tsou, Cheng-Hui Lin, Ching-Song Lee, Nai-Jen Liu, Kai-Feng Sung, Hao-Tsai Cheng
Mu-Hsien Lee, Yung-Kuan Tsou, Cheng-Hui Lin, Ching-Song Lee, Nai-Jen Liu, Kai-Feng Sung, Hao-Tsai Cheng, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan 333, Taiwan
Author contributions: Tsou YK designed research and analyzed data; Lin CH, Lee CS, Liu NJ, Sung KF and Cheng HT performed research and contributed analytic tools; Lee MH wrote the paper and analyzed data.
Institutional review board statement: The study was reviewed and approved by Institutional Review Board of Chang Gung Hospital.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors have no financial disclosures to declare and no conflicts of interest to report.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at flying@adm.cgmh.org.tw.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Yung-Kuan Tsou, MD, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan. flying@adm.cgmh.org.tw
Telephone: +886-3-3281200 Fax: +886-3-3272236
Received: July 21, 2015
Peer-review started: July 30, 2015
First decision: September 29, 2015
Revised: October 30, 2015
Accepted: December 30, 2015
Article in press: December 30, 2015
Published online: March 21, 2016
Abstract

AIM: To predict the re-bleeding after endoscopic hemostasis for delayed post-endoscopic sphincterotomy (ES) bleeding.

METHODS: Over a 15-year period, data from 161 patients with delayed post-ES bleeding were retrospectively collected from a single medical center. To identify risk factors for re-bleeding after initial successful endoscopic hemostasis, parameters before, during and after the procedure of endoscopic retrograde cholangiopancreatography were analyzed. These included age, gender, blood biochemistry, co-morbidities, endoscopic diagnosis, presence of peri-ampullary diverticulum, occurrence of immediate post-ES bleeding, use of needle knife precut sphincterotomy, severity of delayed bleeding, endoscopic features on delayed bleeding, and type of endoscopic therapy.

RESULTS: A total of 35 patients (21.7%) had re-bleeding after initial successful endoscopic hemostasis for delayed post-ES bleeding. Univariate analysis revealed that malignant biliary stricture, serum bilirubin level of greater than 10 mg/dL, initial bleeding severity, and bleeding diathesis were significant predictors of re-bleeding. By multivariate analysis, serum bilirubin level of greater than 10 mg/dL and initial bleeding severity remained significant predictors. Re-bleeding was controlled by endoscopic therapy in a single (n = 23) or multiple (range, 2-7; n = 6) sessions in 29 of the 35 patients (82.9%). Four patients required transarterial embolization and one went for surgery. These five patients had severe bleeding when delayed post-ES bleeding occurred. One patient with decompensated liver cirrhosis died from re-bleeding.

CONCLUSION: Re-bleeding occurs in approximately one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Severity of initial bleeding and serum bilirubin level of greater than 10 mg/dL are predictors of re-bleeding.

Keywords: Delayed bleeding, Endoscopic hemostasis, Endoscopic sphincterotomy, Predictors, Re-bleeding

Core tip: Re-bleeding occurs in about one-fifth of patients after initial successful endoscopic hemostasis for delayed post-ES bleeding. Predictors of re-bleeding has not been studied. Our study reveals malignant biliary stricture, serum bilirubin level of greater than 10 mg/dL, initial bleeding severity, and bleeding diathesis were significant predictors of re-bleeding. These patients often require multiple endoscopic treatments, transarterial embolization or surgery to control the bleeding.