Intra-Abdominal Hemorrhage Following Endoscopic Retrograde Cholangiopancreatography in a Patient with a Cascade Stomach: A Case Report.

Intra-abdominal hemorrhage is an extremely rare complication of endoscopic retrograde cholangiopancreatography (ERCP). We report a case of intra-abdominal bleeding that occurred after ERCP for choledocholithiasis with cholangitis in a patient with a cascade stomach. A man in his 70s underwent ERCP for severe acute cholangitis due to a common bile duct stone. The procedure was initially attempted using a TJF-260 V duodenoscope (Olympus); however, insertion into the duodenum was difficult because of the stomach cascade. The scope was changed to a JF-260 V (Olympus), and duodenal access was successfully achieved using a large-diameter sliding tube (ST-CB1; Olympus), followed by biliary stent placement. No sphincterotomy or other invasive procedure was performed. Two hours after the procedure, the patient developed severe epigastric pain, hypotension, and progressive anemia. Contrast-enhanced computed tomography (CT) revealed a large hematoma centered on the gastrosplenic ligament, indicating an intra-abdominal hemorrhage that was likely caused by a traction injury resulting from scope manipulation. No evidence of contrast extravasation was found, and conservative management was performed. The patient's condition improved with blood transfusion and discontinuation of aspirin, and follow-up CT demonstrated resolution of the hematoma. Inserting a scope can be challenging owing to anatomical deformities such as a cascade stomach, and excessive torque or traction may result in vascular injury. Careful insertion using a sliding tube and positional adjustment are essential, with awareness that intra-abdominal hemorrhage, although rare, can be a serious complication.