Introduction

Upper gastrointestinal (UGI) bleeding in the setting of locally advanced pancreatic adenocarcinoma is a challenging clinical problem, often exacerbated by tumor invasion, altered postoperative anatomy, and friable mucosa. When standard endoscopic strategies are insufficient, a multimodal approach may be required to achieve durable hemostasis. This  case-report describes the complex management of recurrent UGI hemorrhage arising after ERCP and palliative Roux-en-Y gastrojejunostomy in a patient with pancreatic cancer, highlighting the role of sequential endoscopic interventions and covered self-expandable metal stents (SEMS).

Case Presentation

A 78 year-old patient with locally advanced pancreatic adenocarcinoma presented with acute cholangitis characterized by fever, jaundice, and elevated cholestatic markers. ERCP was performed promptly, achieving biliary decompression through successful cannulation and stent placement. Given symptoms of gastric outlet obstruction due to the tumor’s mass effect, the patient subsequently underwent a palliative Roux-en-Y gastrojejunostomy.

During the postoperative period, the patient developed melena accompanied by a significant hemoglobin drop. Urgent endoscopy revealed a bleeding ulcer at the gastro-enteral anastomosis. Hemostasis was initially achieved with norepinephrine injection, followed by thermal coagulation using a Coagrasper device, resulting in short-term stabilization.Over the following weeks, the patient experienced multiple hospital readmissions for recurrent UGI bleeding. Each episode required repeated endoscopic evaluations, but the distorted postoperative anatomy and presence of friable ulcerated tissue limited the effectiveness of conventional techniques. 

Given persistent and recurrent hemorrhage, the multidisciplinary team opted for advanced endoscopic intervention. A fully covered SEMS was positioned across the gastro-enteral anastomosis to tamponade the ulcerated bleeding site. The patient initially improved, but another episode of bleeding occurred, prompting a second endoscopic procedure. A second covered SEMS was deployed to reinforce the area and extend the zone of mechanical hemostasis. Following this intervention, the bleeding resolved definitively.

Discussion and Conclusions

This case illustrates the difficulty of managing recurrent anastomotic ulcer bleeding in patients with pancreatic malignancy and surgically altered anatomy. Multidisciplinary coordination is essential for successful outcomes in such complex postoperative bleeding scenarios. Standard endoscopic hemostatic techniques often fail when bleeding arises from unstable, tumor-influenced tissue. The use of covered SEMS, while more commonly applied for malignant obstruction, proved crucial in achieving sustained hemostasis by exerting tamponade on the ulcerated region and stabilizing the anastomotic site.