Hemorrhage into the bile duct after endoscopic ultrasound-guided fine needle aspiration for pancreatic cancer

A 71-year-old man presented to our department with an elevated serum amylase level of 695 IU/L. Computed tomography revealed a cystic lesion measuring 26 mm in diameter in the pancreatic head ([Fig. 1]). Endoscopic ultrasound (EUS) identified a hypoechoic tumor measuring 15 mm in diameter adjacent to this multilocular cyst. The common bile duct (CBD) was compressed by the tumor without proximal dilation ([Fig. 2]). We performed EUS-guided fine needle aspiration (EUS-FNA) using a 22-gauge Franseen needle from the duodenal bulb in the long scope position. After three punctures, Doppler imaging revealed a turbulent flow signal in the CBD ([Fig. 3]). Subsequently, we confirmed bleeding from the papilla endoscopically ([Fig. 4]). Additionally, hyperechoic clots in the gallbladder were observed endosonographically ([Fig. 5]). The patient remained stable, with a gradual reduction in the turbulent flow signal. Thereafter, we performed endoscopic biliary drainage using a 5-Fr nasobiliary catheter to monitor hemobilia and found no rebleeding. The pathological diagnosis was adenocarcinoma. ([Video 1]).