Endoscopic ultrasound-guided Trucut needle biopsy (EUS-TNB) is new technique for evaluation
and diagnosis of gastrointestinal stromal tumors [1]
[2]
[3]. We report here a patient who developed significant delayed-onset bleeding as a
complication of EUS-TNB of a gastric stromal tumor.
A 50-year-old woman was referred to our hospital for evaluation of a 3-cm submucosal
mass at the gastric cardia. Gastric endosonography performed using a curved linear-array
echo endoscope (GF-UCT240; Olympus Optical Co., Tokyo, Japan) revealed a well-circumscribed,
heterogenous, echo-poor mass, 30 mm × 26 mm in size, arising from the fourth sonographic
layer. Two passes were made into the tumor with a 19-gauge Trucut needle (Quick-Core,
Wilson-Cook, Winston-Salem, North Carolina, USA) to obtain a 9-mm-long tissue core
(Figure [1]). There was no immediate bleeding. Check endoscopy at 24 hours also did not reveal
any local bleeding. The histopathological and immunohistochemical findings were consistent
with a diagnosis of gastric stromal tumor.
Figure 1 Endoscopic ultrasound image of the gastric stromal tumor, showing the Trucut needle
after firing of the cutting sheath.
Nine days later, the patient had developed tarry stools and her hemoglobin had dropped
to 3.9 g/dl. She required transfusion of 8 units of packed red cells. Urgent endoscopy
revealed arterial spurting from an ulcer overlying the submucosal tumor. Bleeding
was stopped temporarily by clipping, but surgical resection was required subsequently.
Histological examination of the resection specimen revealed a large-caliber artery
in the submucosal layer near the ulcer, a picture analogous to rupture of a Dieulafoy
lesion (Figure [2]).
Figure 2 Histological view of the resection specimen. The arrow indicates a large-caliber artery
in the submucosal layer near the ulcer (hematoxylin and eosin stain, × 200 magnification).
Until now, only one case of immediate bleeding after EUS-TNB of a gastrointestinal
stromal tumor has been reported and in that patient hemostasis was achieved by epinephrine
injection [3]. The EUS Trucut needle has a 20-mm tissue tray with an outer cutting sheath. In
the EUS-TNB specimen we took from our patient, no atrophic changes were seen in the
gastric epithelium obtained along with the tumor tissue. We speculate that a post-biopsy
mucosal defect might have evolved into a deep ulcer in the acid-competent stomach,
and that this led to delayed erosion of the underlying submucosal artery. Newer devices
with a shorter needle length should be designed for such small lesions. The routine
use of acid suppressant drugs after biopsy may also decrease the risk of delayed bleeding.
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