LAUSR

Endoscopic sphincterotomy (ES) is a crucial procedure in the treatment of biliary disease, but post-ES bleeding is an occasional adverse event [1]. Massive bleeding makes it difficult to continue the procedure, including hemostasis, because of poor visibility due to coagulum, the narrowness of the duodenum, and technical difficulty of using a side-viewing endoscope. Red dichromatic imaging, a recently developed novel image-enhanced endoscopy technology with good visualization of bleeding points and deep vessels, has been reported to be useful in various situations during upper and lower gastrointestinal endoscopy [2–5]. Herein we present a case in which red dichromatic imaging was useful for hemostasis of massive post-ES bleeding. A 75-year-old-man developed cholangitis due to bile duct stones. Endoscopic retrograde cholangiography was performed with a TJF-Q290V scope with the EVIS X1 system (Olympus Medial Systems, Tokyo, Japan). After biliary cannulation, ES was conducted with a standard sphincterotome. However, massive persistent bleeding occurred immediately. The endoscopic views of the duodenal papilla and the surroundings became red with blood, and it was impossible to identify the bleeding point clearly. The whitelight imaging was therefore switched to red dichromatic imaging. The accumulated residual blood became inconspicuous, and the active blood stream and bleeding point could be visualized in darker yellow (▶Fig. 1, ▶Video 1). Hemostasis was achieved with a local epinephrine injection near the identified bleeding point on red dichromatic imaging. No adverse events and no re-bleeding were observed after the procedure. Red dichromatic imaging confers better visualization of bleeding points and active fresh bleeding, which appears as darker yellow in color. Moreover, pooled residual blood surrounding the active bleeding is less noticeable in red dichromatic imaging; thus, a clear field of view can be obtained compared to white-light imaging. These features can aid hemostatic procedures and in checking whether the bleeding has stopped, even with a side-viewing endoscope and when treating post-ES bleeding. Endoscopy_UCTN_Code_TTT_1AR_2AK