Life-threatening hemorrhage caused by balloon dilation after sphincterotomy for extraction of a large stone.

omy is carried out for stones that are too big [1–7] and also in cases where the terminal bile ducts are too small [1,7]. It was first described in 2003 [1] and is different from balloon sphincteroplasty without sphincterotomy. Severe bleeding following the procedure has been reported only twice [2,3]. A 39-year-old man was referred for ultrasound as his jaundice had not improved 1 month after stopping alcohol. A 16-mm stone, blocking the lower choledochus (●" Fig. 1), was seen along with dilated bile ducts. The bilirubin level was 165 μmol/L and creatinine and coagulation tests were normal. The patient was taking no medication. Retrograde cannulation of the papilla had failed. A needle-knife section of the papilla was easy to carry out and bloodless (●" Fig. 2), as was a sphincterotomy. However, the balloon procedure failed to extract the stone. Progressive dilation with a CRE balloon, 12–15mm (Boston Scientific, Nanterre Cedex, France), allowed disappearance of the notch sign at 15mm (●" Figs. 3 and 4) with the usual technique [1–7]. Total duration of the procedure was 1 minute. Stone extraction with the latex balloon was easily accomplished and elicited routine, low grade oozing of blood (●" Fig. 5). At 2 hours, however, the patient had a massive bleed from a large artery, impeding vision. Injection of 20mL of 1:10000 epinephrine failed to stop the bleeding but surgery involving over-sewing was successful. Bleeding recurred the next day with temporary cardiac arrest. A second attempt at intervention could not visualize the bleeding artery and more of the bleeding region was sewn up. However, the bleeding failed to stop and embolization was carried out to occlude one of the two arteries. The third attempt at intervention succeeded and involved further over-sewing of the papilla. There was evidence of pancreatitis with cytosteatonecrosis. Bleeding did not recur but severe, infected necrotizing pancreatitis and a duodenal fistula necessitated 3 months’ stay in an intensive care unit. A total of 18 units of packed red cells, 16 units of fresh frozen plasma, and 2 units of concentrated platelets were infused. Life-threatening hemorrhage caused by balloon dilation after sphincterotomy for extraction of a large stone