JIMT

Acute upper gastrointestinal bleeding (AUGIB) is a life-threatening emergent event. These events generally require hospitalization and intervention treatment. The mortality rate of AUGIB varies between 3% and 14%, with a commonly reported all-cause 30-day mortality of 9%–14%¹. The predominant causes of AUGIB are nonvariceal, encompassing gastric and duodenal peptic ulcers, mucosal erosive disease of the esophagus, stomach, duodenum, Mallory–Weiss syndrome, Dieulafoy lesion and malignancy. Thus, the milestone of AUGIB is to promptly identify the bleeding source, administer hemostatic treatment, and stabilize the patient’s condition. However, challenging cases in endoscopic hemostasis may necessitate emergency surgery or angiographic embolization.

Esophageal cancer, reported in Globocan 2020, is the sixth leading cause of cancer-related death. Incidence of fistula formation, one of the most fatal complications, is observed in 5.3%–24.1% of patients with esophageal cancer undergoing chemoradiotherapy (CRT)². Esophageal fistula, which mainly communicates with adjacent organs such as the respiratory or cardiovascular system, is a serious complication. Here, we introduce a case of AUGIB through the fistula formation in an unusual organ between the malignant metastatic regional lymph node and abutting the stomach where endoscopic hemostasis was challenging and failed due to unstable vital.

A 57-year-old male with esophageal squamous cell cancer (ESCC) and metastasis to a number of lymph nodes who had undergone 5-fluorouracil/cisplatin chemotherapy with combined radiotherapy (daily 180 cGy in 34 fractions, dose of 6,120 cGy) was referred to the emergency department for hematemesis, hematochezia, and dizziness. On arrival to the emergency department, the patient’s blood pressure was 71/53 mmHg, his heart rate was 121 beats/min, and his mental status drifted to drowsiness. Emergency angiography detected left gastric arterial bleeding (Fig. 1A). After glue embolization, computed tomography confirmed no residual contrast extravasation, but suspicious gastric perforation presenting as a wall discontinuity between the lesser curvature (LC) of the upper gastric body and the abutting lymph node was observed (Fig. 1B). Diagnostic esophagogastroduodenoscopy to confirm communication between the stomach and peritoneal cavity revealed extensive mucosal necrosis with an abnormal opening at the LC to the posterior wall of the upper body, suggestive of an arterio-nodo-gastric fistula (Fig. 1C).

Figure 1. (A) Ongoing extravasation of contrast (arrow) on the left gastric artery. (B) Abdominal computed tomography showing gastric wall defect (arrows) at the posterior wall of the stomach. (C) Endoscopic appearance of arterio-nodo-gastric fistula.

Up to 10%–29% of patients with unresectable T4 stage ESCC receiving CRT develop esophageal fistula^3,4. However, esophageal fistula caused by metastatic lymph nodes is extremely rare⁵. In this case, esophageal cancer with a metastatic left gastric artery (LGA) lymph node eroded into the stomach, resulting in pathologic communication. A plausible explanation for the bleeding could be repeated CRT-induced inflammation causing tumoral feeding vessel (LGA) erosion at the metastatic lymph node and ongoing tumor necrosis and shrinkage. Akiyama et al.⁶ reported that the incidence of ESCC originating from the lower esophagus is 27.7%, with 61.5% of lymph nodes metastasizing to the superior gastric lymph nodes to involve LGA. LGA is the most common embolized artery among esophageal cancer patients with bleeding; although LGA embolization is common, bleeding from the arterio-nodo-gastric fistula that originates from an esophageal metastatic lymph node has not yet been documented.

European Society of Gastrointestinal Endoscopy recommends transcatheter angiographic embolization (TAE) for persistent bleeding refractory to endoscopic hemostasis, with surgery indicated if TAE is unavailable or unsuccessful⁷. Currently, a two-step approach involving endovascular access and subsequent surgical treatment is suggested for aortoesophageal fistula management⁸. Such an approach was adopted for this case as well. Among hemodynamically unstable esophageal cancer patients with upper GI bleeding, TAE primarily aimed at preventing the leakage of blood flow is recommended. Our endoscopic and radiologic findings of unusual bleeding conditions indicate that embolization should be considered the initial strategy in hemodynamically unstable patients with arterial bleeding from a gastric fistula.

Although previous studies have reported technical success rates as high as 90% to 100%⁹, TAE also has technical limitations in the cases of vascular complex anatomy, vascular spasm, and stenosis of the bleeding artery. Embolization, which chemically or physically occludes the feeding artery, preventing bleeding, can lead to rare but potential side effects in the gastrointestinal system such as perforation, necrosis of the gastrointestinal wall, fever, and digestive disturbances. The biggest drawback of TAE includes the potential for rebleeding, which is attributed to factors like incomplete embolization leading to rebleeding, rebleeding from adjacent vessels, and ischemia-related or coagulopathy-induced rebleeding after TAE despite immediate GI bleeding treatment. Therefore, it is mandatory to develop a new endoscopic treatment for a more selective hemostasis than TAE.

In recent, there has been a significant interest in the development of smart hemostatic materials tailored to target internal bleeding sites and enhance hemostasis. Several additional studies have investigated the clinical efficacy of topical hemostatic agents, especially Endoclot (EC, Micro-Tech Europe). However, data on the efficacy of EC are still limited and this is due to a lack of adequate randomization in clinical studies or because Forrest 1a bleeding has not yet been researched⁷. In addition to topical spray, super-thin films, commonly known as nanofilms for hemostasis, have garnered significant attention in the field of nanotechnology. Nanosheet is known to be flexible sufficient to conform to complex substrate topographies and adhere tightly to the substrate even in wet conditions, which appears promising technique compared to conventional hemostatic methods¹⁰. Currently, TAE is widely utilized as an alternative therapy to endoscopic treatment. However, introducing new technologies and treatments, such as nanofilms, and nanosheets, would be beneficial in future endoscopic treatments.

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No potential conflict of interest relevant to this article was reported.

None.