How to manage a patient with hypotension, haematemesis, and melena after a failed Endoscopic Retrograde Cholangiopancreatography (ERCP) due to perforation?

Management of Hypotension, Haematemesis, and Melena After Failed ERCP with Perforation

Laparotomy (option D) is the most appropriate management for this hemodynamically unstable patient with perforation and active bleeding after failed ERCP. 1

Rationale for Immediate Laparotomy

• Patients with ERCP perforations who are hemodynamically unstable (BP 80/50) should be surgically managed without attempting endoscopic closure 1
• The combination of hypotension, haematemesis, and melena indicates active bleeding requiring immediate intervention 1
• In patients with ongoing resuscitative needs and hemodynamic instability following perforation, conservative or endoscopic management is contraindicated 1

Initial Stabilization (While Preparing for Laparotomy)

• Immediate fluid resuscitation and blood product administration should be initiated while preparing for definitive surgical intervention 1
• Hemodynamic stability is the key factor in determining management strategy, and this patient is clearly unstable with BP 80/50 1

Why Other Options Are Not Appropriate

• Repeat endoscopy (option A): Not appropriate because the patient is hemodynamically unstable with active bleeding and a known perforation 1
• Laparoscopy (option B): Not the first choice because in hemodynamically unstable patients with perforation, open surgery provides better exposure and faster control of bleeding 1
• Coeliac angiography embolization (option C): Not appropriate when there is a known perforation that requires surgical repair, as it would only address the bleeding but not the perforation 1

Benefits of Laparotomy in This Scenario

• Allows direct visualization and repair of the perforation 1
• Provides immediate control of bleeding source 1
• Enables thorough abdominal lavage to reduce risk of sepsis 1
• Addresses both the perforation and bleeding simultaneously 1

Important Considerations

• ERCP-related perforations are severe adverse events with a high mortality rate (up to 20%) if not managed promptly 2
• There should be a high index of suspicion for perforation when abdominal signs and symptoms develop after ERCP 3
• Delayed intervention can significantly increase morbidity and mortality 3

Common Pitfalls to Avoid

• Attempting conservative management in hemodynamically unstable patients with perforation can lead to worse outcomes 1
• Delaying surgical intervention in the presence of active bleeding and perforation increases mortality risk 1
• Underestimating the severity of the perforation based on initial presentation 3