Use of the Ella Danis stent in esophageal bleeding due to severe reflux esophagitis

A 79-year-old woman presented with hematemesis. As upper gastrointestinal tract bleeding was suspected, acute gastroduodenoscopy was performed. This showed reflux esophagitis with multiple ulcerations (Los Angeles classification grade D) and oozing hemorrhage (Forrest Ib) in the lower third of the esophagus ([Fig. 1 a]).

Fig. 1 Endoscopic images showing: a reflux esophagitis grade D (Los Angeles classification) with bleeding (Forrest Ib) from a large area of ulceration; b no further active bleeding after placement of an Ella Danis stent; c the vascular stump that had previously bled after the Ella Danis stent had been extracted 5 days later.

The bleeding was originating from a large area of ulceration, so clipping or injection of epinephrine would have been associated with a risk of causing further bleeding. We therefore decided to place an Ella Danis stent (flare diameters, 30 mm; body diameter, 25 mm; length, 135 mm; Ella-CS, Hradec Kralove, Czech Republic). After the stent had been expanded, the hemorrhage stopped immediately ([Fig. 1 b]). The stent stayed in place as a result of its expansion forces; no anchor or clipping was needed. Hemostasis was maintained during the following days.

After 5 days, the stent was carefully removed with a forceps without using an overtube. There was considerable improvement in the esophageal appearance with no signs of active bleeding. The vascular stump that had previously bled could still be seen ([Fig. 1 c]). Two days later the patient was discharged without any further complications.

The use of stents for esophageal bleeding was originally reported for acute variceal hemorrhage when endoscopic band ligation could not be performed or was unsuccessful [1] [2]. More recently it has been used to treat bleeding from an esophageal ulcer after endoscopic band ligation [3]. Other publications have reported the successful off-label use of the Ella Danis stent in bleeding due to complications after mucosectomy or sphincterotomy, necrotizing esophagitis, as well as in anastomotic leakage [3] [4] [5].

So far, there are no data available concerning the safe application of an Ella Danis stent in acute hemorrhage due to severe reflux esophagitis. As there is not sufficient data on efficacy, safety, and complications, further investigation is needed; however, the Ella Danis stent appears to be a promising tool in the endoscopic treatment of a broad spectrum of causes of acute nonvariceal esophageal bleeding.

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• References

• 1 Hubmann R, Bodlaj G, Czompo M et al. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 2006; 38: 896-901
• 2 Wright G, Lewis H, Hogan B et al. A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010; 71: 71-78
• 3 Mishin I, Ghidirim G, Dolghii A et al. Implantation of self-expanding metal stent in the treatment of severe bleeding from esophageal ulcer after endoscopic band ligation. Dis Esophagus 2010; 23: E35-E38
• 4 Wong Kee Song LM, Banerjee S, Barth BA et al. Emerging technologies for endoscopic hemostasis. Gastrointest Endosc 2012; 75: 933-937
• 5 Messner Z, Gschwantler M, Resch H et al. Use of the Ella Danis stent in severe esophageal bleeding caused by acute necrotizing esophagitis. Endoscopy 2014; 46 (Suppl. 01) E225-E226