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proving the visualization of some areas of the gastrointestinal tract [1]. A few re− ports exist on the use of a cap attached to the tip of a front−viewing gastroscope to facilitate the endoscopic view of the pa− pilla of Vater. We describe the use of cap−assisted endoscopy to achieve hemo− stasis of an ampullary vessel bleeding after endoscopic sphincterotomy. A 20−year−old female inpatient under− went endoscopic retrograde cholangio− pancreatography (ERCP) with endoscopic sphincterotomy without immediate com− plications for choledocholithiasis; 48 hours later she developed upper gastroin− testinal bleeding. She presented with bright red hematemesis, tachycardia, hy− potension, and weakness. Her hemoglo− bin dropped to 7 g/dL (from 13.8 g/dL at baseline). An urgent upper endoscopy using a front− view endoscope showed no source of bleeding from esophagus and stomach, but active duodenal bleeding. Because the bleeding site was suspected to be at the sphincterotomy and a lateral−view endoscope was not available, we decided to load the endoscope with a transparent straight cap from a six−shooter multiband variceal ligator (Wilson±Cook Medical, Inc., Winston−Salem, North Carolina, USA). We passed into the second portion of duodenum, obtaining a frontal view of the papilla of Vater and clearly identify− ing the bleeding point at the sphinctero− tomy (l" Fig. 1). Sclerotherapy of the bleeding vessel with adrenaline 1:10000 (3mL) injected with a 25−gauge needle was successful in con− trolling the hemorrhage (l" Fig. 2). An adequate and stable position was ob− tained with the transparent cap against the papilla of Vater. We verified satisfac− tory hemostasis and terminated the pro− cedure (l" Fig. 3). From the experience of this case, we be− lieve that in situations when a lateral− view endoscope is not readily available, using a gastroscope armed with a trans− parent straight cap can facilitate the en− doscopic view of the papilla of Vater and might also bring some cost saving bene− fits.

Use of a gastroscope armed with a transparent cap in the treatment of bleeding after endoscopic sphincterotomy