Delayed perforation 10 days after endoscopic hemostasis using hemostatic forceps for a bleeding Dieulafoy lesion

To our knowledge, there have been no reports in the English literature of cases of delayed perforation occurring more than 2 days after hemostasis for gastrointestinal bleeding, including bleeding related to endoscopic submucosal dissection. Additionally, according to previous reports [1] [2], in patients with delayed perforation, surgery was often required to improve their clinical course. We report a rare case of successful conservative treatment for delayed perforation occurring 10 days after endoscopic hemostasis using hemostatic forceps for a bleeding Dieulafoy lesion.

An 83-year-old man was admitted to our hospital for the treatment of early gastric cancer. The patient underwent pylorus-preserving gastrectomy and lymph node dissection. On postoperative day 26, he had massive hematemesis. Emergent endoscopy showed a bleeding Dieulafoy lesion at the greater curvature of the gastric remnant ([Fig. 1 a]). The bleeding point was grasped and coagulated with hemostatic forceps (Coagrasper, FD-410LR; Olympus, Tokyo, Japan), using the soft coagulation mode at 80 W ([Fig. 1 b]). Follow-up endoscopic examinations showed no evidence of delayed bleeding at the hemostatic site on days 3 and 7 after the hemostasis procedure ([Fig. 2]). However, on day 10 after hemostasis, the patient complained of severe upper abdominal pain. Free air and ascites were seen in the peritoneal cavity on emergent computed tomography and endoscopic examination revealed a perforation of 3 mm in diameter in the hemostatic ulcer ([Fig. 3 a]). The perforation was closed endoscopically with nine endoclips (HX-600-090L; Olympus) ([Fig. 3 b]). The general condition of the patient as well as the laboratory data and radiographic findings gradually improved, and 40 days after the perforation he was discharged.

Fig. 1 Emergent endoscopic examination after hematemesis in an 83-year-old man who had undergone treatment for early gastric cancer. a Dieulafoy lesion is located at the greater curvature of the gastric remnant with arterial bleeding. b The bleeding point was coagulated with hemostatic forceps using the soft coagulation mode at 80 W.

Fig. 2 Follow-up endoscopic view showing absence of delayed bleeding and perforation at the hemostatic site on days 3 (a) and 7 (b) post hemostasis.

Fig. 3 Emergent endoscopy 10 days after hemostasis. a A 3-mm perforation is visible in the hemostatic ulcer (arrow). b The perforation closed with nine endoclips.

Endoscopy_UCTN_Code_CPL_1AH_2AC

Competing interests: None

• References

• 1 Hanaoka N, Uedo N, Ishihara R et al. Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer. Endoscopy 2010; 42: 1112-1115
• 2 Ikezawa K, Michida T, Iwahashi K et al. Delayed perforation occurring after endoscopic submucosal dissection for early gastric cancer. Gastric Cancer 2012; 15: 111-114