Combined ERCP and endoscopic ultrasonography: a new treatment for rare hemorrhage from a duodenal papillary vascular malformation

Vascular malformation is the main cause of gastrointestinal bleeding, especially in patients with hemorrhage of unknown origin, accounting for approximately 10 % – 40 % of cases [1]. Endoscopic treatment is common; techniques include epinephrine injection [2], contact coagulation [3], and band ligation [4]. However, hemorrhage from a duodenal papillary vascular malformation is rare and challenging to treat; it has always been treated with papillectomy [5]. We present a new treatment using endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) for cases of this kind.

A 28-year-old man was admitted to our hospital with a 7-month history of black stool, dizziness, and fatigue. Laboratory data were normal except for hemoglobin (56 g/L). A thorough examination including computed tomography, magnetic resonance imaging, EUS, and Doppler ultrasonography led us to conclude that the anemia was being caused by hemorrhage from a duodenal papillary vascular malformation ([Fig. 1], [Fig. 2] and [Fig. 3]).

Fig. 1 Gastroscopy in a 28-year-old man revealed an enlarged duodenal papilla, a tear near the opening of the papilla, and active bleeding.

Fig. 2 Endoscopic (EUS) and Doppler ultrasonography showed a multicolored mass with eddy currents.

Fig. 3 EUS and Doppler spectral analysis revealed venous blood flow.

As the patient’s vascular malformation was close to the paths of the biliary and pancreatic ducts, a plastic biliary stent (7 Fr/7 cm; Boston Scientific, Marlborough, Massachusetts, USA) and a plastic pancreatic stent (5 Fr/7 cm; Cook Medical, Bloomington, Indiana) were first placed with the help of ERCP to protect these ducts from possible damage by lauromacrogol ([Fig. 4]). After successful stent placement, 1 ml lauromacrogol was injected into the culprit vessel under EUS guidance (Expect EUS-FNA, 25 G, 0.52 mm; Boston Scientific). Doppler ultrasonography confirmed that after EUS-guided treatment the blood flow in the lesion had stopped almost completely ([Video 1]), and the patient’s general condition remained very good. One month later, gastroscopy revealed that the duodenal papilla surface mucosa was well recovered, and the biliary and pancreatic stents were removed. Three months later, the patient’s duodenal papilla had completely returned to normal ([Fig. 5]), and the laboratory data showed a hemoglobin concentration of 145 g/L. Our treatment has successfully protected the function of the duodenal papilla and cured the hemorrhage from the vascular malformation.

Fig. 4 Both a plastic biliary duct stent and a plastic pancreatic duct stent were placed under ERCP guidance.

Video 1 Combined ERCP and endoscopic ultrasonography (EUS), a new treatment for rare hemorrhage from a duodenal papillary vascular malformation. After EUS-guided treatment, the blood flow in the lesion stopped almost completely.

Fig. 5 The shape of the duodenal papilla had returned to normal after 3 months.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Munitiz Ruiz V, Garcia Perez B, Serrano Jimenez A. et al. Multiple angiodysplasia of the small intestine. A diagnostic and therapeutic challenge. Gastroenterol Hepatol 2004; 27: 311-313
• 2 Gonzalez JM, Ezzedine S, Vitton V. et al. Endoscopic ultrasound treatment of vascular complications in acute pancreatitis. Endoscopy 2009; 41: 721-724
• 3 Boustière C, Dumas O, Jouffre C. et al. Endoscopic ultrasonography classification of gastric varices in patients with cirrhosis. Comparison with endoscopic findings. J Hepatol 1993; 19: 268-272
• 4 Fockens P, Meenan J, van Dullemen HM. et al. Dieulafoy’s disease: endosonographic detection and endosonography-guided treatment. Gastrointest Endosc 1996; 44: 437-442
• 5 Artifon EL, Sakai P, Luz GO. et al. Bleeding angiodysplasia of the major duodenal papilla: how should it be handled?. Clinics 2006; 61: 277-278

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Artikel online veröffentlicht:
13. Juli 2020