Abdominal Pain After Endoscopic Hemostasis of Gastric Tumor Bleeding

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• Answer to the Clinical Challenges and Images in GI Question: Image 4: Splenic Infarction With Abscess Formation
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Question: A 56-year-old man was sent to our emergency department because of hematemesis. He had completed concurrent chemoirradiation 3 years previously for esophageal squamous cell carcinoma with esophageal–cardiac junction involvement and metastatic pre-carinal lymph node metastases, and had regular surveillance visits at our oncology division. He had no history of peptic ulcer disease, alcohol consumption, or liver cirrhosis. Physical examination revealed pale conjunctiva, mild epigastric tenderness, tachycardia (heart rate, 112 bpm) and hypotension (blood pressure, 87/59 mmHg). Laboratory data showed a hemoglobin level of 6.7 g/dL (normal, 14–18), white blood count, 13.4 × 10⁹/L (normal, 4.5–11 × 10⁹/L); platelets, 254 × 10⁹/L (normal, 150–350 × 10⁹/L); prothrombin time, 10.6 seconds (normal, 8.0–12.0); international normalized ration, 0.98 (normal, 0.85–1.15); activated partial thromboplastin time, 24.9 seconds (normal, 23.9–35.5); blood urea nitrogen, 35 mg/dL (normal, 7–20), serum creatinine, 0.9 mg/dl (normal, 0.7–1.5); serum sodium, 137 mmol/L (normal, 135–147); and serum potassium, 4.2 mmol/L (normal, 3.4–4.7). A blood transfusion was given and esophagogastroduodenoscopy was performed. The endoscopy revealed an ulcerative gastric tumor at the posterior wall near the cardia, with a large oozing vessel at the ulcer base (Figure A). Two milliliters of a 1:1 mixture of N-butyl-2-cyanoacrylate (Histoacryl, B Braun Medical Inc, Bethlehem, PA) and Lipiodol was injected into the tumor for hemostasis.

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Persistent left upper quadrant pain was noted soon after the endoscopy. A plain abdominal x-ray was obtained on postoperative day 3 (Figure B), and abdominal sonography were performed on postoperative day 8 (Figure C). What is the most likely diagnosis for this patient?

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Answer to the Clinical Challenges and Images in GI Question: Image 4: Splenic Infarction With Abscess Formation 

The abdominal radiograph disclosed a curvilinear radiopaque density in the left upper quadrant, and abdominal sonography demonstrated a hypoechoic lesion in the spleen. Abdominal computed tomography revealed high-density material extending from the gastric wall to the splenic hilum, near-total occlusion of the splenic artery and its branches, and a cystic mass with an air–fluid level in the spleen (Figure D). Splenic infarction with abscess formation was diagnosed. Despite the lack of infection signs, prophylactic antibiotics were administered. The patient developed spiking fever, leukocytosis, and septic shock 12 days after endoscopy. Percutaneous abscess drainage was initiated and culture demonstrated Peptostreptococcus species; the antibiotic regimen was changed based on susceptibility test results. The patient's condition gradually stabilized and he was discharged on day 50.

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Endoscopic injection of Histoacryl had been established as an effective therapy for bleeding gastric varices. In addition, successful hemostasis with Histoacryl injection had also been reported in ruptured duodenal varices, bleeding peptic ulcers, and Dieulafoy lesions. Currently, there is very little published literature on the treatment of arterial gastrointestinal tumor bleeding. Successful treatment with Histoacryl injection into the bleeding gastric tumor had been described by Rosa et al in 2000.¹

Many local and distal thromboembolic complications of Histoacryl injection in gastric varices had been documented, including portal vein thrombosis, splenic vein thrombosis, pulmonary embolism, coronary emboli, renal vein embolism, inferior vena cava embolism, cerebral emboli, retroperitoneal abscess, septicemia, and even splenic infarction.² To the best our knowledge, splenic infarction and abscess formation after Histoacryl injection for bleeding gastric tumor has not been reported. Splenic infarction usually has a benign and self-limited clinical course. Only 7% of patients with splenic infarction require splenectomy because of sepsis, abscess, or persistent pain.³ Clinicians should be aware of this unusual complication of Histoacryl injection.

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References 

1. Rosa A, Sequeira C, Macoas F, et al. Histoacryl in the endoscopic treatment of severe arterial tumor bleeding. Endoscopy. 2000;32:S69
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2. Kok K, Bond RP, Duncan IC, et al. Distal embolization and local vessel wall ulceration after gastric variceal obliteration with n-butyl-2-cyanoacrylate: a case report and review of the literature. Endoscopy. 2004;36:442–446
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3. Cheng PN, Sheu BS, Chen CY, et al. Splenic infarction after Histoacryl injection for bleeding gastric varices. Endoscopy. 1998;48:426–427
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