Application of hemostatic forceps to treat post-sphincterotomy bleeding near the pancreatic duct opening

A 36-year-old man underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy, which resulted in the extraction of several large stones. A 10-mm × 4-cm fully covered metal stent was placed in the bile duct and a 5-Fr × 4-cm flapless straight plastic stent in the pancreatic duct. The patient returned to the emergency department 2 days later complaining of dizziness, melanic stool, and a syncopal event. His hemoglobin showed a downward trend of 16 to 8.3g/dL. The patient underwent esophagogastroduodenoscopy, which showed active oozing with an adherent clot at the sphincterotomy site at the inferior aspect of the major papilla ([Fig. 1]). The biliary stent was removed for better visualization, the clot was suctioned, and epinephrine (1:10 000) was injected around the site. Next, a hemostatic forceps (coagrasper) was utilized to inspect and expose the area ([Fig. 2]). Blood was seen to be issuing near the pancreatic duct as well as a visible vessel at the apex of the papilla ([Video 1]). Because of the tight space and the risk of clipping the pancreatic duct, the coagrasper was used to achieve hemostasis. Before applying coagulation, the ampulla was submerged under water to decrease the risk of thermal burn to the thin duodenal wall ([Fig. 3]). A 10-mm × 4-cm biliary stent was deployed, and a 5-Fr × 4-cm stent was placed in the pancreatic duct to prevent post-procedure pancreatitis.