A 35-year-old man presented with dysphagia accompanied by regurgitation for 2 years,
with his symptoms having worsened over the previous 3 months. After a series of comprehensive
examinations, he was diagnosed with type 2 achalasia and underwent a successful peroral
endoscopic myotomy (POEM). He developed chest pain 9 hours after the operation, which
was accompanied by a small amount of hematemesis, and persisted without relief. An
emergency gastroscopy indicated bleeding within the tunnel, so endoscopic hemostasis
was performed with the patient under general anesthesia with tracheal intubation.
During the gastroscopy, the tunnel was seen to be obviously swollen, and bleeding
within the tunnel was therefore considered. The tunnel opening was re-established
endoscopically, and a large number of dark red blood clots were observed ([Fig. 1]
a). Removing the blood clots from the tunnel and finding the bleeding site were the
key and most challenging aspects in achieving hemostasis. At first, a snare was tried
to clear the blood clots; however, the tunnel filled with blood clots lacked sufficient
space to open the snare. In contrast, with a clip, it was possible to more effectively
grasp and remove the blood clots with fibrosis, thereby improving the efficiency of
blood clot clearance. After spending 50 minutes clearing all the blood clots from
the tunnel ([Fig. 1]
b), we identified active oozing of blood from a blood vessel in the submucosa at the
cardia ([Fig. 1]
c). Hemostasis was performed by electrocoagulation under endoscopic visualization and
was successfully achieved ([Fig. 1]
d; [Video 1]).
Fig. 1 Endoscopic images showing: a the re-incised swollen tunnel, containing a large number of dark red blood clots;
b the tunnel after clearance of all the blood clots; c active oozing of blood from a blood vessel in the submucosa of the cardia; d the appearance after hemostasis was successfully achieved by electrocoagulation.
Clearance of clots from the tunnel and identification of the bleeding site allows
successful management of delayed bleeding after peroral endoscopic myotomy for achalasia.Video
1
Re-examination 10 days after the operation showed no evidence of further bleeding
in the tunnel ([Fig. 2]), and the patient was then discharged from the hospital.
Fig. 2 Endoscopic image showing no evidence of further bleeding in the tunnel and the clips
still in position to seal the tunnel opening.
Bleeding within the tunnel after a POEM operation is extremely rare [1]. Once it occurs, dealing with it can be troublesome [2]. In cases of massive bleeding, the key to hemostasis lies in clearing the blood
clots inside the tunnel to allow identification of the bleeding site.
Endoscopy_UCTN_Code_CPL_1AH_2AZ_3AZ
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