Endoscopic management of active arterial bleeding in walled-off necrosis collection

Bleeding related to drainage of walled-off necrosis (WON) via a lumen-apposing metal stent (LAMS) and subsequent endoscopic necrosectomy is a known adverse event of the procedure. Typically, these bleeds are managed by interventional radiology. This case demonstrates successful endoscopic management of bleeding from a WON cavity.

A 45-year-old female underwent EUS-guided cystagsastrostomy with a LAMS for a large, symptomatic WON collection. Six days after the procedure, she presented with hematemesis. Computed tomography angiography showed blood products in the WON cavity but no active arterial extravasation. The decision was made to pursue endoscopic evaluation with EGD.

During EGD, extensive clot extraction and removal of the LAMS allowed discovery of a pulsatile vessel in the WON cavity. This was treated with coagulation grasper forceps, ligation of vessel with hemostatic clips, and peptide matrix gel. She had no further bleeding, and WON collection resolved.

This case portrays successful endoscopic therapy for bleeding within a WON cavity. Normally, bleeding after placement of a LAMS is managed by interventional radiology. However, endoscopic therapy should be considered when imaging does not reveal active arterial extravasation or if the bleeding is intermittent in nature.