Extravasation of sclerosant after injection of N-butyl-2-cyanoacrylate for a bleeding gastric Dieulafoy lesion

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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

References

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