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EUS-directed transgastric endoscopy for upper gastrointestinal bleeding

1 ABC Medical Center: Departamento de Endoscopia gastrointestinal Centro Medico ABC, CDMX, Mexico
2 Universidad Anahuac, Naucalpan de Juárez, Mexico
3 Departamento de Endoscopia gastrointestinal Hospital Angeles Pedregal, CDMX, Mexico

Date of Submission19-Nov-2021
Date of Acceptance15-Feb-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Katia Picazo-Ferrera,
ABC Medical Center: Centro Medico ABC, CDMX
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00254

PMID: 35899904

How to cite this URL:
Picazo-Ferrera K, Ytuarte-Orantes E, Ballesteros-Amozurrutia MA, Soto-Solis R. EUS-directed transgastric endoscopy for upper gastrointestinal bleeding. Endosc Ultrasound [Epub ahead of print] [cited 2022 Dec 1]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=351310

A 64-year-old man who had undergone a Roux-en-Y gastric bypass presented because of massive upper gastrointestinal bleeding. The diagnostic and initial therapeutic approach included an upper-endoscopy and colonoscopy without finding the bleeding source. After blood transfusions and hemodynamic stability was reached, a computed tomography angiography was performed. Finding an active extravasation of contrast in the duodenal bulb. After discussion of options, a EUS-directed transgastric endoscopy was proposed. A linear echoendoscope (GF-UCT180; Olympus America, Center Valley, Pa, USA) was advanced into the gastric pouch. Under US guidance, the excluded stomach was located. Under fluoroscopic and US guidance, the remnant stomach was punctured with a 19-gauge EUS needle. As a safety measure; sterile water, methylene blue, and contrast material were injected. Through endosonographic vision a 15-mm × 10-mm cautery-enhanced, lumen-apposing metal stent (LAMS, Axios; Boston Scientific, Natick, Mass, USA) was inserted [Figure 1] creating a gastrogastric fistula between the pouch and the remnant stomach. A gastroscope (GIF-HQ190, Olympus America) was then inserted, followed by a 12 mm CRE balloon (CRE™ Single-Use WIREGUIDED Balloon Dilator) used for dilatation [Figure 2]. The scope was advanced to the duodenal bulb, finding a Forrest IIa ulcer. Conventional endoscopic treatment was performed with submucosal epinephrine injection and mechanical hemostasis with clips [Figure 3]. The LAMS was left until it was verified that there was no rebleeding risk. Bariatric surgery modifies patient's anatomy and physiology, bleeding duodenal ulcer are usually treated with urgent laparotomy or interventional radiology.[1] EUS-directed transgastric procedures may offer a minimally invasive, effective option, with less resource utilization in modified anatomy patients that require endoscopic access to gastric remnant for therapeutic procedures.[2],[3] To the best of our knowledge, this was the first edge procedure used as a therapeutic measure for bleeding in patients with modified anatomy.
Figure 1: EUS gastro-gastric fistula

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Figure 2: LAMS ballon dilatation

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Figure 3: Conventional endoscopic treatment

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ivanecz A, Sremec M, Ceranić D, et al. Life threatening bleeding from duodenal ulcer after Roux-en-Y gastric bypass: Case report and review of the literature. World J Gastrointest Endosc 2014;6:625-9.  Back to cited text no. 1
Kedia P, Kumta NA, Widmer J, et al. Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: A novel technique. Endoscopy 2015;47:159-63.  Back to cited text no. 2
Vallabh H, Poushanchi B, Hsueh W, et al. EUS-directed transgastric ERCP (EDGE) with use of a 20-mm×10-mm lumen-apposing metal stent in a patient with Roux-en-Y gastric bypass. VideoGIE 2018;3:262-3.  Back to cited text no. 3


  [Figure 1], [Figure 2], [Figure 3]


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