Severe Ulceration of the Stomach after Endoscopic Injection Sclerotherapy

Endoscopic injection sclerotherapy (EIS) is a major therapeutic modality for the treatment of patients with bleeding from ruptured esophageal varices [1]. In addition, it has been demonstrated that prophylactic sclerotherapy in cirrhotic patients with known varices can reduce the rate of subsequent bleeding and improve survival [2]. The complications of endoscopic sclerotherapy include, for example, esophageal ulceration and esophageal perforation [3]. However, few reports have focused on the development of gastric ulcers following sclerotherapy [4].

A 45-year-old man was admitted to our hospital with liver cirrhosis due to hepatitis virus B and esophageal varices. His varices were classified as LiF₂CbRC(+)Lg-cf(+) according to the general rules for study of portal hypertension [5]. About 5 months prior to admission, he had undergone three uneventful sessions of sclerotherapy for risk-associated esophageal varices. At 3 days after admission, he underwent EIS; a total of 10 ml of 5 % ethanolamine oleate was injected into several large varices at different sites under radiographic guidance (Figure [1]). The patient had a moderate degree of upper epigastric discomfort following the procedure. The abdominal pain increased and the patient vomited blood on the morning after the procedure. A subsequent endoscopy examination revealed a large gastric ulcer in the lesser curvature of the gastric body (Figure [2]). A computed tomography examination also showed a low-density area in the lesser curvature of the gastric body. The giant gastric ulcer, which responded to conservative therapy, appeared to be healing at 1 month after the sclerotherapy.

Figure 1 Endoscopic varicealography performed during endoscopic injection sclerotherapy (EIS) shows the left gastric vein through the fundic plexus; however the left gastric artery branch is not visible.

Figure 2 Endoscopic image showing a giant gastric ulcer on the lesser curvature of the gastric body, 1 day after the EIS.

In view of its location, the giant gastric ulcer may have formed because of ischemia as a result of arterial obstruction by the sclerosant. Only one previous report has focused on the formation of gastric ulcers following sclerotherapy. Asano et al. [4] reported that a gastric arterial branch was detected in a portion of an ulcer by means of varicealography; however we did not observe any gastric arterial branches in the present case. Giant gastric ulcer is a very rare but serious complication of sclerotherapy.

References

• 1 Allison J G. The role of injection sclerotherapy in the emergency and definitive management of bleeding esophageal varices.  J Am Med Assoc. 1983;  249 1484-1487
• 2 Paquet K J. Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices - a prospective controlled randomized trial.  Endoscopy. 1982;  14 4-5
• 3 Bacon B R, Camara D S, Duffy M C. Severe ulceration and delayed perforation of the esophagus after endoscopic variceal sclerotherapy.  Gastrointest Endosc. 1987;  33 311-315
• 4 Asano A, Kokubu S, Murakami M. et al . A case of autoimmune hepatitis with giant ulcer of the stomach after EIS for recurrent esophageal varices; visualization of left gastric artery in endoscopic varicealography.  Gastroenterol Endosc. 1997;  39 2397-2403
• 5 Idezuki Y. General rules for recording endoscopic findings of esophagogastric varices (1991). Japanese Society for Portal Hypertension.  World J Surg. 1995;  19 420-423