Upper gastrointestinal bleeding poses a significant threat to the lives of affected individuals. Endoscopic treatment has become the preferred approach due to its timeliness, accuracy, and intuitive nature. Endoscopic sclerotherapy (ES) has gained prominence in the management of gastroesophageal varices bleeding, primarily by inducing thrombosis through vascular endothelial injury.
However, its application in treating non-variceal gastrointestinal bleeding, such as anastomotic tumor hemorrhage, remains limited. In this case report, we present a successful instance of ES for anastomotic tumor hemorrhage after subtotal gastrectomy, shedding light on a novel approach for managing such cases. This Case report is covered by the DEN OPEN Wiley.
A 71-year-old male patient presented with recurrent melena persisting for over nine months, attributed to anastomotic tumor bleeding diagnosed through gastric endoscopy. Nine months earlier, the patient experienced melena, accompanied by dizziness and fatigue. Gastroscopy revealed an anastomotic mass with a surface ulcer, a result of a prior gastrectomy (Billroth II) procedure, and residual gastritis.
Biopsy and pathological examination confirmed poorly differentiated adenocarcinoma at the anastomotic site. During the nine-month period, the patient received only blood transfusion therapy, consistently refusing surgery due to underlying coronary atherosclerotic heart disease. The patient had undergone subtotal gastrectomy (Billroth II) for duodenal ulcer treatment over 20 years ago. Physical examination revealed pallor, pale skin, and mucous membranes, consistent with anemia.
Laboratory tests demonstrated an erythrocyte count of 3.67×10^12/L, hemoglobin levels of 63g/L, and platelet count of 399×10^9/L. Fecal occult blood tests yielded positive results, while coagulation function and other laboratory parameters remained within normal limits. The diagnosis reaffirmed anastomotic carcinoma bleeding post-subtotal gastrectomy, chronic hemorrhagic anemia, and moderate anemia.
Surgery was once again declined due to the patient’s coronary atherosclerotic heart disease. However, the patient ultimately consented to endoscopy for hemostasis. ES, a technique primarily used in esophageal variceal bleeding, involves thrombosis induced by vascular endothelial injury. The application of ES for anastomotic malignant tumor bleeding, as in this case, represents a novel approach with minimal invasiveness compared to surgical resection.
In the procedure, Lauromacrogol was injected into the submucosa to block submucosal blood flow. When the nourishing artery of the carcinoma exhibited spurting bleeding, tissue glue was precisely injected into the blood vessel through the puncture needle. The use of tissue glue injection as an intravascular approach ensured minimal tissue necrosis and minimized the risk of rebleeding.
Post-ES gastroscopy revealed no active hemorrhage, and the size of the carcinoma appeared reduced after one month. Several factors may have contributed to tumor shrinkage, including the direct damage to vascular endothelium by Lauromacrogol, promotion of thrombosis, and subsequent tissue fibrosis, leading to vascular occlusion and tumor atrophy.
Furthermore, rapid coagulation of tissue glue immediately blocked the bleeding nutrient artery. Submucosal injection led to necrosis and shedding of the tumor. The procedure’s safety was reinforced by the precise delivery of only 1ml of tissue glue to the rupture site, minimizing the risk of ectopic embolization. Additionally, the minimal 0.2 ml of Lauromacrogol injected at each point prevented extensive ulceration or perforation. This approach proved both safe and reliable.
The treatment of anastomotic tumor hemorrhage presents various challenges, including the risk of vascular injury and ulcer base damage when using conventional methods like argon plasma coagulation or high-frequency soft coagulation. While interventional radiology is another option for tumor bleeding,
it was not chosen initially due to concerns about potential complications, such as ischemic necrosis of anastomotic tissue or anastomotic fistula post-embolization. In this unique case, ES successfully addressed anastomotic tumor hemorrhage after subtotal gastrectomy, highlighting its potential as an effective and minimally invasive treatment option.
Further long-term observation is necessary to assess the durability of this treatment strategy. If rebleeding occurs during follow-up, consideration may be given to interventional embolization as an alternative approach. This case underscores the importance of exploring innovative interventions to manage complex gastrointestinal bleeding scenarios, offering patients viable alternatives to traditional surgical options.
