Rupture of a pseudoaneurysm caused by endoscopic papillary large-balloon dilation.

Endoscopic papillary large-balloon dilation (EPLBD) is a relatively new technology for removing large bile duct stones [1]. The efficacy and safety of EPLBD have been reported; however, severe complications occur in approximately 10% of patients [2]. Hemorrhage is one of the most common complications, and endoscopic hemostasis is effective [3]. Herein, we present a case of rupture of a pseudoaneurysm following EPLBD. A 71-year-old woman with recurrent bile duct stones was admitted to our institution. She had a previous history of recurrent episodes of acute pancreatitis. A large stone, 28×10mm in size, was seen on computed tomography (●" Fig.1). Contrast-enhanced computed tomography was not performed because of the patient's renal dysfunction. Endoscopic retrograde cholangiography revealed an oblong-shaped filling defect in the common bile duct (●" Fig.2a). EPLBD with a balloon catheter (CREWireguided Balloon Dilator, 15–18 mm; Boston Scientific, Natick, Massachusetts, USA) was performed to remove the bile duct stone (●" Fig.2b). Spurting bleeding was observed immediately after the balloon had been deflated (●" Fig.3a). Neither balloon oppression nor placement of a fully covered self-expandable metallic stent with a diameter of 10mm was effective for hemostasis (●" Fig.3b). Emergency abdominal angiography was performed, and angiography of the gastroduodenal artery revealed a pseudoaneurysm of the gastroduodenal artery with extravasation into the duodenum (●" Fig.4a,●" Fig.4b). The placement of five coils achieved complete hemostasis (●" Fig.5). The patient was discharged on postoperative day 9 without further complications. To our knowledge, this is the first report of pseudoaneurysm rupture as a complication of EPLBD. Because this patient had a history of recurrent episodes of acute pancreatitis, a pseudoaneurysm was possible. However, we had no chance to notice the pseudoaneurysm because contrast-enhanced computed tomography was contraindicated owing to her renal dysfunction. Care should be taken to evaluate patients undergoing EPLBD with contrast-enhanced computed tomography to detect any arterial abnormality.