해외 증례(Japan) Emergency Endoscopic Hemostasis Using the Endoscopic Mucosal Resection Technique for Severe Bleeding From Early Gastric Cancer: A Case Report

관리자
2024-04-05
조회수 22

Cureus. 2024 Feb 18;16(2):e54429. doi: 10.7759/cureus.54429. eCollection 2024 Feb. 

AIG환자의 EGC 병변에서 발생한 bleeding control을 위해 emergency endoscopic modality로써 EMR을 시행하였던 case 입니다.


85/Male 

C/Cx: Hematemesis

P/Hx: Hypertension

LAB: Severe anemia (Hb: 4.7g/dL) -> transfusion and FFP (각각 4 units) 사용에도 Hb (6.6 g/dL) 및 출혈 등이 호전되지 않아 전원 됨. 


Emergency EGD revealed a 45 mm-sized elevated lesion involving coagula associated with blood dripping from the surface of the posterior wall of the gastric lower body, as well as a 15 mm-sized elevated lesion in the anterior wall of the gastric lower body, on white light imaging (WLI) (Figure 1A). EMR was performed, with an abdominal surgeon present, for endoscopic diagnosis of bleeding from early gastric cancer, as well as for hemostasis, which was achieved immediately (Figure 1B-1D).


Figure 1. Esophagogastroduodenoscopy (EGD). 

Emergency EGD revealed a 45 mm-sized elevated lesion (arrows) with coagula attached due to blood dripping from the surface of the posterior wall of the gastric lower body (A). Endoscopic mucosal resection (EMR) was performed, and hemostasis was achieved immediately (B-D).

 

Histological examination of the lesion from the posterior wall of the gastric lower body showed a papillotubular adenocarcinoma (pap-tub), type 0-I, measuring 45 x 30 mm, pT1a (M) (Figure 2A, bleeding area; Figure 2B, tumor area). Histopathology of the second lesion obtained from the anterior wall of the gastric lower body was consistent with papillotubular adenocarcinoma (pap-tub), type 0-Ip, measuring 15 mm, pT1a (M). 


Figure 2. Pathological findings. 

Histological examination revealed the lesions to be a papillotubular adenocarcinoma (pap-tub), type 0-I, measuring 45 x 30 mm, pT1a (M) (3A, bleeding area; 3B, tumor area). 


A repeat EGD performed 5 days after hemostasis revealed a 20 mm-sized hyperplastic polyp in the anterior wall of the prepyloric lesion (Figure 3A), pan-atrophy without atrophic border (Figure 3B), small hyperplastic polyps in the greater curvature of the gastric angle (Figure 3C), and a 20 mm-sized, reddish, elevated lesion in the posterior wall of the gastric angle on WLI (Figure 3C). On texture and color enhancement imaging mode 1 with indigo-carmine dye, the lesion was highlighted as a reddish elevated and depressed type lesion (Figure 3D), which biopsy revealed as adenocarcinoma.


Figure 3. Repeat esophagogastroduodenoscopy (EGD). 

A repeat EGD performed 5 days after hemostasis revealed a 20 mm-sized, hyperplastic polyp in the anterior wall of the prepyloric lesion (3A), pan-atrophy without atrophic border (3B), small hyperplastic polyps in the greater curvature of the gastric angle (3C) and a 20 mm-sized, reddish, elevated lesion in the posterior wall of the gastric angle on WLI (3C), which was highlighted as a reddish, elevated and depressed type lesion (3D) on texture and color enhancement imaging mode 1 with indigo-carmine dye and biopsy confirmed as an adenocarcinoma. 


He was shown to be positive for anti-parietal cell antibodies but negative for H. pylori on a stool antigen test and the biopsy, suggesting the presence of autoimmune gastritis. To accommodate the availability of his family living far away, the patient was discharged on day 19 of hospitalization without rebleeding and was readmitted 2 months later for surgical treatment of early gastric cancer and hyperplastic polyp. Endoscopic submucosal dissection (ESD) was performed on early gastric cancer in the posterior wall of the gastric angle, and EMR was performed on the hyperplastic polyp in the anterior wall of the prepyloric lesion. Histological examination revealed the first lesion obtained from the posterior wall of the gastric angle to be an adenocarcinoma, pap, type 0-IIa+IIc, measuring 20' 16 mm, pT1a (M), with no lymphovascular invasion. Histological examination of the second lesion obtained from the anterior wall of the prepyloric lesion showed a hyperplastic polyp.

The patient was thus diagnosed with synchronous triple gastric cancer associated with autoimmune gastritis. Since then, the patient has been visiting our hospital regularly for 3 years and taking a potassium competitive acid blocker. A follow-up EGD and computed tomography examinations have shown no evidence of recurrence to date.


Conclusions 

The endoscopic and pathological images offered here should provide a clear illustration of the case made for endoscopic hemostasis using the EMR technique. Further studies are needed to determine whether endoscopic hemostasis using the EMR method may prove useful for severe bleeding from early gastric cancer. In addition, early gastric cancer may present as a synchronous lesion associated with autoimmune gastritis. Clinicians need to be aware of the characteristics of early gastric cancer associated with autoimmune gastritis.


<Abstract>

Bleeding from gastric cancer may lead to severe anemia and hypovolemic shock, and can be a life-threatening condition in affected patients; thus, achieving hemostasis is essential to improving their clinical course. While endoscopic hemostasis is recommended as the hemostatic modality of first choice, endoscopic hemostasis involving the endoscopic mucosal resection (EMR) technique is also being used, though under-reported. An 85-year-old man diagnosed with bleeding from gastric cancer was raced to our hospital for hemostasis. Emergency esophagogastroduodenoscopy (EGD) revealed a 45 mm-sized elevated lesion involving the coagula due to dripping bleeding from the surface of the posterior wall of the gastric lower body. EMR was performed without any technical difficulty, and hemostasis was achieved immediately. The patient was discharged without rebleeding. This case appears to support the usefulness of EMR as an emergency endoscopic hemostatic modality for severe bleeding from early gastric cancer.

Keywords: gastric cancer, endoscopic mucosal resection, autoimmune gastritis, endoscopic hemostasis, bleeding

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대한자가면역성위염연구회

주소 : 경기도 용인시 기흥구 중부대로 579, 508-23호 (구갈동, 강남대프라자)

대표전화 : 070-8080-0453  이메일 : autogastritis@gmail.com 


Copyright (c)대한자가면역성위염연구회. All Rights Reserved. Design Hosting By 위멘토.