A 79-year-old woman was admitted because she had been passing tarry stools for 2 days.
Emergency endoscopy revealed an actively spurting Dieulafoy lesion in the gastric
fundus ([Fig. 1]). Because of the technical difficulty of applying hemoclips in this case we performed
rubber-band ligation, which resulted in immediate hemostasis ([Fig. 2]). Twelve hours later, fresh blood reappeared in the nasogastric aspirate. A repeat
endoscopy showed active oozing from the base of the ligated area ([Fig. 3]). Despite the injection of 12 mL of diluted epinephrine, the bleeding persisted.
After discussing the situation with the patient she agreed to receive a sclerosant
injection, and the bleeding stopped after an injection of a mixture of 0.5 mL of N-butyl-2-cyanoacrylate
and lipiodol. The patient complained of dull epigastric pain after the injection,
and a chest radiograph showed radiopaque material along the left diaphragm ([Fig. 4]). Abdominal computed tomography confirmed that there was extravasation of sclerosant
along the left subphrenic area ([Fig. 5]). The patient was free of any signs of infection and was discharged on day 6 of
her hospital day. She remained well over the following 2 years.
Fig. 1 An actively spurting Dieulafoy lesion in the gastric fundus.
Fig. 2 The bleeding was controlled immediately after endoscopic band ligation.
Fig. 3 Repeat endoscopy revealed active oozing from the base of the ligated area.
Fig. 4 The chest radiograph showed radiopaque material along the left diaphragm (arrow).
Fig. 5 Abdominal computed tomography showed extravasation of sclerosant along the left subphrenic
area (arrows).
Endoscopic therapy is now a mainstay of treatment for Dieulafoy lesions. Several authors
have documented hemostasis rates for endoscopic band ligation of 80 % – 100 % in case
series of patients with Dieulafoy lesions [1]
[2]. However, the optimal rescue therapy after failed endoscopic band ligation is not
known. In the present case, injection therapy with diluted epinephrine failed to control
the bleeding. Hemoclipping or coagulation therapy would have been technically difficult.
It was believed that repeated band ligation would increase the risk of gastric perforation
[3], and so Histoacryl injection was chosen as the last resort before surgery [4]. Despite the successful hemostasis, the complication of injection-site leakage and
resultant transient abdominal pain are concerning. This might have been caused by
direct penetration of the gastric wall by the injection needle. The short-term outcome
of sclerosant extravasation in this case and in another reported case [5] was good, but it is still not clear what the long-term effects of this complication
are.
Endoscopy_UCTN_Code_CPL_1AH_2AC
