LAUSR

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective treatment for high-risk surgical cholecystitis and its use is gradually becoming more widespread. According to metaanalyses, the frequency of bleeding is low (1.8–4.3%) [1, 2]. We report a case of arterial bleeding from a gallbladder ulcer after EUS-GBD that was successfully cauterized endoscopically and hemostasis was achieved. An 85-year-old man, who had been admitted to another hospital with Parkinson’s disease and cerebral infarction, was transferred to our hospital with acute cholecystitis (▶Fig. 1). He was deemed high risk for surgery and had an age-adjusted Charlson Comorbidity Index score of 6. Therefore, he underwent EUS-GBD with a fully covered self-expandable metal stent (FCSEMS). Computed tomography (CT) performed the day after EUSGBD showed insufficient space between the FCSEMS and gallbladder wall, and the FCSEMS was in contact with the gallbladder mucosa (▶Fig. 2). The patient was discharged and readmitted 68 days later for melena. Arterial phase CT showed a migrated FCSEMS and extravasation into the bile ducts (▶Fig. 3). An admission endoscopy revealed a clot at the fistula (▶Fig. 4). Following fistula dilation using a balloon catheter, an endoscope was inserted into the gallbladder. Although there was no active bleeding, a blood vessel was found at the ulcer, which we cauterized for 7 s (▶Fig. 5). Anemia progressed 12 days later, and a repeat endoscopy showed a large number of clots in the gallbladder. During clot removal, spurting bleeding was observed (▶Video 1). Hemostatic forceps were used to stop the bleeding, and cauterization was performed. No further bleeding occurred. Mechanical stimulation of the gallbladder wall by the FCSEMS may be considered a cause of gallbladder ulceration and hemorrhage; therefore, the FCSEMS should be placed in an area with sufficient space.