Ampullary polyp resection as treatment for severe GI bleeding

A 50-year-old woman presented with melena that required transfusion. EGD revealed ampullary bleeding (Video 1, available at www.giejournal.org). She was transferred to our institution with a hemoglobin count of 7 gm/dL and hemodynamic instability. Duodenoscopy revealed a 1-cm bleeding lesion projecting from the superior portion of the ampulla (Fig. 1A ). EUS showed a villous projection, 9 mm × 3 mm, with no invasion into the submucosa. Color flow Doppler ultrasonography identified a vessel within the lesion (Fig. 1B). ERCP demonstrated no intraductal invasion or abnormalities. Coagulation or endoclip application would probably not have eradicated the bleeding polyp; therefore, ampullary polyp resection was performed to treat her life-threatening bleeding. The ampullary polyp was lifted by the injection of epinephrine (1:10,000) diluted in normal saline solution and then removed en bloc by use of a hot snare and coagulation current. Biliary and pancreatic sphincterotomies were performed, and a 5F × 4-cm plastic stent was placed into the ventral pancreatic duct to reduce the risk of pancreatitis. After polypectomy, the patient’s bleeding ceased. Pathologic examination revealed an inflammatory polyp. Follow-up EGD 4 months later demonstrated no ampullary abnormality. Bleeding is a known adverse event of ampullary resection or papillectomy. However, ampullary polyp resection as treatment for life-threatening ampullary bleeding is exceedingly rare.