The choice of type of additional endoscopic therapy after
epinephrine injection for bleeding peptic ulcers should be carefully
individualized according to the characteristics of the ulcer.
A 56-year-old man with diabetes mellitus was admitted with a 24-hour
history of hematemesis and melena. On physical examination, his blood arterial
pressure was 100/60 mmHg and heart rate 120/min. The hemoglobin level
was 10.8 g/dL. Endoscopy showed fresh blood in the stomach and a 12-mm
ulcer in the antrum with active oozing bleeding from a flat visible vessel
(Forrest Ib classification). Injection of 8 mL of epinephrine
(1/10 000 solution) on the edges of the ulcer did not stop bleeding ([Fig. 1]). Consequently, sclerotherapy with
ethanolamine oleate (EO) was carried out and, immediately after injection of
1.5 mL a purplish protruding lesion appeared besides the ulcer ([Fig. 2]), which prevented the endoscopist from
further administering EO. Hemostasis was successfully achieved after combined
sclerotherapy ([Fig. 3]). After 48 h, the
patient experienced abdominal pain and severe re-bleeding. Endoscopy revealed
a
deep ulcer covering half of the surface of the distal antrum ([Fig. 4]). Emergency vascular computed tomography
ruled out arterial thrombosis. The patient was discharged after proton pump
inhibitor perfusion and wide spectrum antibiotherapy for 1 week. A follow-up
endoscopy 3 months later showed full resolution of the lesion.
Fig. 1 Epinephrine injection on
the edges of a gastric ulcer with active oozing bleeding.
Fig. 2 Immediately after
injecting ethanolamine oleate, a purplish protruding lesion (arrows) appeared
besides the ulcer, indicating vascular injury.
Fig. 3 Final hemostasis at the
ulcer after combined sclerotherapy, with the vascular lesion (white arrows) and
a remarkable swollen ischemic ring (black arrows).
Fig. 4 While the former ulcer
was almost healed, a deep complex ulcer, covered with a giant clot and filling
half of the distal antrum, was observed during endoscopy 48 h later, due
to re-bleeding.
Several case reports in the early 1990s highlighted the risk of
extensive gastrointestinal necrosis following sclerosant plus epinephrine
injection for bleeding ulcers [1]
[2]
[3]
[4].
Interestingly, spleen infarction has been recently reported following
high-volume epinephrine injection in a gastric bleeding vessel, without
sclerosants [5]. Inadvertent intra-arterial injection may
result in either spasm or thrombosis leading to subsequent tissue ischemia or
necrosis. Endoscopists should be aware of this rare complication. Lower volumes
of sclerotherapy, lower speed of injection, avoiding the visible vessel and
using alternative endoscopic therapies (clips, argon plasma coagulation) may
minimize its occurrence.
Endoscopy_UCTN_Code_CCL_1AZ_2AC
