Unusual Cause of Severe Upper Gastrointestinal Hemorrhage Treated Using a Simple Endo-Loop Technique

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The endo-loop technique appears to be a very promising and useful tool in the control of gastrointestinal bleeding. We report a case of successful treatment of severe gastrointestinal hemorrhage from the duodenum.

A 41-year-old woman suffering from cold-like symptoms had taken aspirin three times a day for 7 days. The following week she observed tarry stools and experienced massive hematemesis. Endoscopy did not identify any source of such bleeding, although fresh blood was seen in the descending duodenum. Subsequently, the patient underwent operation because of massive hematemesis with hypovolemic shock. The operation showed only nonbleeding gastric erosions, and no real source of bleeding was found. The patient needed 12 units of blood replacement before she could be moved to our department for a second endoscopy. The examination revealed spurting bleeding from a protruding polypoid-like mucosal lesion, 2 cm in diameter, located just below the papilla of Vater (Figure [1]). Using an endo-loop ligation device, a single loop was successfully placed and tightened around the base of the visible lesion. The following day, endoscopic examination showed no bleeding from the lesion with the endo-loop in place (Figure [2]). A histological examination of a mucosal specimen, obtained by biopsy forceps, showed collagen strands and cells of the neural tissue with low mitotic index, heterogeneous in density, variable in size, and having unclear, crude chromatin tumor nuclei; on this basis we considered this therapy to be definitive. The patient had no recurrent bleeding.

Figure 1Bleeding from the neurinoma located below the previously cannulated papilla of Vater (arrow)

Figure 2Examination the following day shows the endo-loop in place

Neurinomas are only occasionally found in the duodenum [1] [2] . Typically they are submucosally located, and overt gastrointestinal hemorrhage may appear only from an ulceration of the mucosa covering the tumor. It is possible that aspirin was the trigger mechanism for the bleeding in our patient [3].

The polypoid-like lesion provided an opportunity to use the endo-loop to stop the spurting bleeding. We strongly believe that in some cases this easy and elegant technique may improve the success rate of endoscopic therapy for life-threatening bleeding from the upper gastrointestinal tract.

References

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