title: Clinically significant delayed postsphincterotomy bleeding: a twelve year single center experience.
abstract: OBJECTIVE
  Bleeding following endoscopic biliary sphincterotomy (ES) is associated with morbidity. We sought to identify endoscopic findings and outcome of patients with delayed bleeding after ES.
  
  
  METHODS
  A retrospective study was carried out in a tertiary referral center. A gastrointestinal bleeding and endoscopy database was used to identify all patients with delayed post-ES bleeding from 1994 to 2006. Early endoscopic evaluation and endoscopic hemostasis was performed. Endoscopic findings, factors associated with bleeding severity, identification of stigmata of hemorrhage, and success of endoscopic treatment were identified.
  
  
  RESULTS
  There were 84 patients with delayed post-ES bleeding. Bleeding was classified as mild in 31 (36.9%), moderate in 29 (34.5%), and severe in 24 (28.6%). Thirteen of these 84 (15.5%) experienced bleeding at the time of initial ES. Endoscopic findings for evaluation of bleeding included active bleeding in 50 (59.5%) and stigmata of recent bleeding in 34 (40.5%) patients. Endoscopic treatment was employed in 74 (88%) patients. Monotherapy was used in 39.2% and combined therapy was used in 60.8% patients. Recurrence of bleeding was significantly more common in the severe group (P<0.001). A multivariate analysis showed that coagulopathy was a predictive factor for severe post-ES bleeding.
  
  
  CONCLUSIONS
  Active bleeding or stigmata of hemorrhage occurs in the majority of patients with clinically significant delayed post-ES bleeding. Endoscopic therapy is useful in controlling bleeding in nearly all cases, though multimodal therapy and repeat endoscopic procedures may be required. Coagulopathy is a risk factor for severe bleeding; preventive measures in these patients may reduce morbidity.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: L E V V C
authors.initials: LE
authors.lastname: Ferreira
authors.forename: J
authors.initials: J
authors.lastname: Fatima
authors.forename: T H
authors.initials: TH
authors.lastname: Baron
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects*; D013997:Time Factors