S3259 Necrotizing Pancreatitis From Ampullary OTSC Misplacement: ERCP Clip Removal in a Critically Ill Patient

Introduction: Over-the-scope clips (OTSC; Ovesco) are effective for refractory GI bleeding but carry risks of misplacement. Accidental ampullary closure can lead to life-threatening biliary obstruction and pancreatitis. We present a high-risk case of OTSC-induced pancreatitis complicated by necrotic collections, managed with endoscopic retrograde cholangiopancreatography (ERCP)-guided clip removal. Case Description/Methods: A man patient in 70s with history of chronic obstructive pulmonary disease, pulmonary hypertension, and tobacco use presented with encephalopathy from hypercapnic/hypoxic respiratory failure. During hospitalization, he developed melena and was found to have duodenal ulcers with a visible vessel. Hemostasis was achieved with over-the-scope (Ovesco) clip placement, but the clip inadvertently closed the ampulla, causing acute pancreatitis (lipase >17,000 U/L) and hyperbilirubinemia (peak total bilirubin 8.2 mg/dL). ERCP confirmed ampullary obstruction, but duodenal edema and inflammation made cannulation challenging. The OTSC was successfully removed, resulting in immediate bile drainage. Despite improvement in bilirubin, the patient developed a left-sided peripancreatic acute necrotic collection on computed tomography-scan, requiring prolonged intensive care unit care for CRRT-dependent acute kidney injury and pain management. Discussion: OTSC misplacement over the ampulla, though rare, can lead to catastrophic outcomes and necessitates urgent removal. While ERCP-guided clip removal is technically demanding in inflamed anatomy, it is feasible and effective. This case underscores the importance of risk stratification when placing OTSCs near the ampulla, highlights the potential for delayed ischemic pancreatic injury even after successful clip removal, and reflects the multidisciplinary challenges in managing critically ill patients. Real-time endoscopic confirmation of clip placement and early biliary decompression are essential to mitigate severe complications.