Endoscopic Ultrasound Detection of Active Bleeding During Endoscopic Transmural Drainage of Walled.Off Necrosis

Sir,

A 37-year-old male presented with abdominal pain, early satiety, and palpable upper abdominal lump of 3 weeks duration. He was diagnosed with alcohol-related necrotizing pancreatitis 4 months ago. Computed tomography of the abdomen revealed a large, walled-off necrosis (WON) compressing the stomach along with splenic vein thrombosis. Endoscopic ultrasound (EUS) revealed large walled-off pancreatic necrosis along with multiple perigastric collaterals. Under EUS guidance, avoiding collaterals, the WON was punctured using 19G needle and thereafter, a 0.035-inch guidewire was coiled inside WON, and the transmural tract was dilated over the wire using 8 mm dilating hydrostatic balloon under EUS guidance [Figure 1]. Following dilatation, a spurt of echogenic contents was observed from the dilated site [[Figure 2]a; arrows]. On active suction, fresh blood was aspirated from the biopsy channel of the echoendoscope. Immediately, a biflanged fully covered self-expanding metallic stent (total length 3 cm; diameter 16 mm, and diameter of flanges: 28 mm) was placed across the transmural tract. On the opening of the internal flange of the stent and consequent tamponade, the bleeding stopped immediately, as evident by cessation of spurting echogenic contents on EUS [Figure 2]b. Post-procedure patient remained asymptomatic, and there was no recurrence of bleed.

Figure: Endoscopic ultrasound: The transmural tract being dilated over the wire using 8 mm dilating hydrostatic balloon under endoscopic ultrasound guidance

Figure: (a) Endoscopic ultrasound: Spurt of echogenic contents being observed from the dilated site. (b) Endoscopic ultrasound: bi.flanged fully covered self.expanding metallic stent being deployed leading to cessation of bleeding

Postendoscopic transmural drainage bleeding may be minor that stops spontaneously or may require endoscopic interventions or angioembolization or surgery. Traditional endoscopic hemostatic interventions are technically difficult in postcystogastrostomy bleed because of difficulty in localizing the site of bleed. Various hemostatic methods used for controlling such bleed described in the literature are the placement of metallic stents, angiography, and embolization, endoscopic glue injection or clip application after visualization of bleeding vessel, and endoscopic hemospray application.[1], [2] Fully covered self-expandable metal stent can promote hemostasis by providing mechanical tamponade effect and have been shown to be effective in stopping postcystogastrostomy bleed.[1]

• REFERENCES

• 1 Itoi T, Ijima M, Kobatake T, Kurihara E, Watanuki Y, Okuno N. et al. Hemostasis by using a fully covered self-expandable biliary metal stent for massive bleeding during EUS-guided cystogastrostomy. Gastrointest Endosc 2014; 80: 726-7
• 2 Rana SS, Singhal M, Sharma A, Sharma V, Yadav MK, Gupta R. et al. Successful hemostasis of arterial bleeding in chronic pseudocyst by direct endoscopic injection of N-butyl-2-cyanoacrylate in the pseudoaneurysm. Gastrointest Endosc 2015; 81: 1046-7