Endoscopic management of bleeding after endoscopic ultrasound-guided drainage of a pancreatic pseudocyst

A 64-year-old man was admitted to our hospital with abdominal bloating. Computed tomography revealed a pancreatic pseudocyst located caudal to the body of the pancreas (▶Fig. 1). Endoscopic ultrasound (EUS)-guided pancreatic pseudocyst drainage was performed. We used a 19-gauge fine-needle aspiration needle to target the gastric wall. A 0.035-inch guidewire was advanced through the needle and the tract was dilated to 12mm. A plastic double-pigtail stent and a nasal cystic drainage tube (7 Fr) were then placed into the passageway between the stomach and the cyst. The patient developed massive hematemesis less than 24 hours after drainage of a pancreatic pseudocyst. He underwent immediate endoscopy, which revealed a large blood clot in the stomach lumen, with active bleeding still visible after rinsing with saline (▶Fig. 2). We considered the bleeding site to be at the puncture site but, unfortunately, the continuous bleeding in the stomach cavity made it impossible to visualize the bleeding site or the position of the stent. The acoustic shadow of the stent was however detected by EUS in the stomach cavity (▶Fig. 3 a), and the stent was removed with foreign body forceps (▶Fig. 3b). The nasal cystic drainage tube was replaced with a guidewire, and a partially covered self-expandable metal stent (SEMS) was placed over the guidewire (▶Fig. 4 a). A E-Videos