Successful use of a fully covered metal stent for refractory bleeding from a duodenal cancer

A 69-year-old man visited our emergency department because of the intermittent passage of tarry stool. At endoscopy, an ulcerated, oozing mass was found in the third portion of the duodenum ([Fig. 1]). Furthermore, abdominal computed tomography revealed multiple hepatic tumors and a duodenal tumor ([Fig. 2], arrow). Biopsy specimens from both sites revealed adenocarcinoma, and a diagnosis of duodenal cancer with multiple hepatic metastases was established. Despite the parenteral administration of proton pump inhibitor therapy, the passage of tarry stools persisted, and the patient was dependent on transfusions. Four attempts at endoscopic therapy, including argon plasma coagulation and epinephrine injection, all failed to control the bleeding. The patient was not considered for surgery because of unresectable malignancy. He was put on parenteral nutrition, but the bleeding continued for a month.

Fig. 1 Endoscopic view of a bleeding ulcerated tumor of the duodenum, successfully managed with a fully covered metal stent.

Fig. 2 Abdominal computed tomography reveals multiple hepatic tumors and an ulcerative tumor in the duodenum (arrow).

Because of the persistent bleeding with a requirement for daily transfusion, it was decided to use a Niti-S Comvi stent (TaeWoong Medical, Gyeonggi-do, South Korea) for tamponade of the bleeding tumor ([Fig. 3]). Three days following placement of the metal stent, the passage of tarry stool started to decrease, and the patient resumed an oral diet. He was discharged 37 days after admission without further bleeding.

Fig. 3 Endoscopic view after the placement of a fully covered metal stent over the duodenal tumor.

The use of an enteral metal stent is indicated mainly for the palliative management of malignant intestinal tract obstruction in patients with advanced malignancy of the esophagus, duodenum, stomach, pancreas, or colon [1]. Fully covered metal stents have also been used to treat esophageal perforation [2] and variceal bleeding [3]. The present case demonstrates that a fully covered metal stent can be a salvage tool [4] for the management of bleeding duodenal cancer when conventional endoscopic measures fail.

Endoscopy_UCTN_Code_TTT_1AO_2AF

Competing interests: None

• References

• 1 Kochar R, Shah N. Enteral stents: from esophagus to colon. Gastrointest Endosc 2013; 78: 913-918
• 2 Yen HH, Chen YY. Pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after ultrathin endoscopy. Endoscopy 2011; 43 (Suppl. 02) E49-E50
• 3 Holster IL, Kuipers EJ, van Buuren HR et al. Self-expandable metal stents as definitive treatment for esophageal variceal bleeding. Endoscopy 2013; 45: 485-488
• 4 D’Souza PM, Sandha GS, Teshima CW. Refractory bleeding from a malignant duodenal ulcer treated with placement of a fully-covered gastroduodenal stent. Dig Dis Sci 2013; 58: 3359-3361