INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is defined as bleeding within the gastrointestinal (GI) tract that occurs proximal to the ligament of Treitz and is a common cause of GI-related hospitalization.1,2 GI bleeding related to a malignancy is a common etiology of UGIB and is challenging to manage, often presenting with multiple episodes of recurrent bleeding even after achieving initial hemostasis. Endoscopic therapies commonly used for UGIB related to malignancies include injection (eg, epinephrine, ethanol) therapy, mechanical (eg, endoclips, band) therapy, thermal therapy, and hemostatic spray powder.3–5 In addition, endoscopic suturing has been used for managing refractory bleeding from peptic ulcer disease that cannot be managed with conventional endoscopic hemostatic techniques. However, studies evaluating outcomes of endoscopic suturing are limited to small series.6 There is currently limited knowledge regarding the use of endoscopic suturing in malignancy-related UGIB. In this study, we describe a case of the successful endoscopic closure of a bleeding malignant gastric ulcer using endoscopic suturing.

CASE REPORT

A 60-year-old man with a history of gastroesophageal reflux disease and primary thrombocytopenia underwent an esophagogastroduodenoscopy for the evaluation of abdominal pain. Esophagogastroduodenoscopy revealed an ulcer in the proximal lesser curvature of the stomach with diffuse gastric fold thickening. Pathology confirmed signet-ring adenocarcinoma. A positron emission topography scan showed mild uptake in celiac axis/gastrohepatic lymph nodes, and the patient underwent staging endoscopic ultrasound. Endoscopic ultrasound showed diffuse wall thickening in the cardia, lesser curvature, and body of the stomach, primarily due to thickening within the muscularis propria concerning for linitis plastica, and staging was suspected to be T2 N2. The patient was started on a chemotherapy regimen consisting of 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel.

Four days after initiation of chemotherapy, the patient presented to the emergency department with 3 days of intractable nausea and vomiting. This was presumed to be chemotherapy-induced gastritis because he had no significant nonsteroidal anti-inflammatory drug use and a negative infectious workup. The patient was started on antiemetics and intravenous hydration. On hospital day 3, the patient developed hematemesis and melena and hemoglobin dropped to 7.8 g/dL from 15.0 g/dL 4 days earlier. He was hypotensive and tachycardic and transferred to the intensive care unit and was eventually intubated for airway protection. An urgent upper endoscopy showed active oozing and bleeding from a cratered gastric ulcer (previously biopsy-proven adenocarcinoma) on the proximal lesser curvature measuring approximately 20 mm in size (Figure 1A). Diffuse thickening of gastric folds consistent with linitis plastica was also seen. Initial attempts with bipolar cautery and epinephrine injection were unable to achieve hemostasis. An over-the-scope endoscopic suturing system (OverStitch ESS; Apollo Endosurgery, Austin, TX) was used to place a suture in a figure-of-8 fashion and cinched at the end with closure of the ulcer bed (Figure 1B). The ulcer bed was not visible after suturing, and hemostasis was achieved (Figure 1C). Repeat upper endoscopy after 2 months showed no evidence of the ulcer with the cinch in place (Figure 1D). However, after three months of follow-up, the patient was readmitted with coffee-ground emesis and superficial ulceration was seen at the site of the prior ulcer, which was treated with hemostatic spray powder. Follow-up imaging at that time revealed distant metastasis of the cancer, and the patient and family opted to pursue hospice care.

Figure 1.:

(A) Endoscopic image of gastric adenocarcinoma and associated cratered ulcer with oozing hemorrhage. (B) Endoscopic suturing assisted closure. (C) Endoscopic image of successfully approximating edges of the ulcer after endoscopic suturing without evidence of bleeding. (D) Endoscopic image of the suture cinch in place, with no evidence of the ulcer on the 2-month follow-up.

DISCUSSION

Malignancy-related GI bleeding accounts for up to 5% of UGIB-related hospitalizations in the United States.3 Interventions, such as surgical or endoscopic resection, are at times the only definitive treatment, but this is not an option for all patients. Endoscopic interventions are the mainstay for treatments of bleeding related to malignancies. One study showed that, in these patients, a combination of electrocoagulation with hemostatic forceps or argon plasma coagulation achieved hemostasis in 93% of patients studied, although rebleeding rates were as high as 41%.7 Another study looked at endoscopically administered hemostatic powder for tumor-related bleeding (as part of bridging therapy) in 105 patients and found that immediate hemostasis was achieved in 97% of patients, with rebleeding occurring in 15% of them.8 Injection of ethanol and/or epinephrine has similarly been studied in these patients, although often they are used as supplementation with other endoscopic therapies.9

Endoscopic suturing has primarily been used for closure of defects in the GI tract, such as perforations, leaks, and fistulas, and is used for endobariatric procedures.10 There are reports of the successful use of this suturing for managing challenging peptic ulcer disease-related GI bleeding, although data are limited because the technical skills and resources required are prohibitive in many healthcare settings. The largest case series available demonstrated successful immediate hemostasis after suturing in a cohort of 10 patients, 9 of whom had bleeding refractory to other endoscopic interventions, with no evidence of early or delayed rebleeding.11 Another instance of using endoscopic suturing for peptic ulcer-related GI bleeding was in a critically ill patient with similar bleeding refractory to prior endoscopic treatment and transarterial embolization. Endoscopic suturing being offered as salvage therapy before high-risk invasive surgical interventions and hemostasis was achieved with favorable patient outcomes.12

Endoscopic suturing is a relatively new technology that shows promise for use in multiple GI-related circumstances. To our knowledge, this is the first case of the successful use of endoscopic suturing for the closure of a bleeding malignant gastric ulcer. We hypothesize that the success of this case could have been in part because of the nature of linitis plastica being known to create markedly thickened and rigid tissue because of infiltration of the submucosa and muscle layer.13 This likely facilitated adequate tissue purchase at the margins of the bleeding gastric ulcer, which would typically be precluded in malignant tissue because of its friable nature. Our case highlights that endoscopic suturing can be used in select cases of malignancy-related upper gastrointestinal bleeding. In our case, the patient had durable hemostasis for 3 months, which allowed the patient to undergo chemotherapy. Unfortunately, the patient developed distant metastasis and was unable to receive curative surgery.

DISCLOSURES

Author contributions: M. Andreone, B. Megna, N. McDonald, and M. Bilal wrote the manuscript. All authors were involved in drafting and editing the manuscript. M. Bilal is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

Previous presentation: This case was presented at the American College of Gastroenterology Annual Meeting; October 24, 2022; Charlotte, North Carolina, where it was awarded a Presidential Poster Award.

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