Post written by Radhika Chavan, MD, DNB, from the Ansh Clinic, Ahmedabad, Gujarat, India.

A 24-year man diagnosed with a type II gastric neuroendocrine tumor (NET) (size <20 mm) underwent endoscopic submucosal dissection (ESD) after multidisciplinary discussion. During distal extension of the initial incision, bleeding started and abruptly became profuse. Initial attempts to control the bleeding using hemostatic forceps and an over-the-scope clip were unsuccessful, as bleeding source visualization was difficult from ongoing bleeding.

Positional changes (left lateral to supine, semiprone) were attempted to visualize the bleeding source but remained ineffective. The patient developed hemodynamic instability, so all necessary supports including intravenous fluids, packed cell volume, and vasopressor were administrated, and an interventional radiologist and surgeons were consulted for a potential transfer.

To reduce the patient’s risk of mortality from ongoing bleeding while transferring, a linear echoendoscope was used to localize the bleeding source. On EUS, a large spurting vessel was localized near a hypoechoic lesion in the proximal body. The vessel was targeted with a 19-gauge needle, and glue mixed with lipiodol was injected.

Post-glue injection, bleeding ceased and could be localized with a gastroscope. With the gastroscope, 0.5 mL was injected additionally for safety. The patient was transferred to the intensive care unit. Hemodynamic parameters gradually improved, and all support was tapered in 2 days. After a smooth recovery with no further bleeding, the patient resumed a diet and was discharged in stable condition on day 4.

This case highlights the role of EUS in managing life-threatening bleeding when the source is obscured within a pool of blood. EUS enabled precise localization of the vessel and facilitated therapeutic intervention when conventional techniques failed because of inability to visualize the bleeding.

The location of the bleeding vessel in the proximal body of the stomach was favorable for EUS-guided intervention, and submersion of the vessel in blood provided excellent acoustic coupling for EUS visualization, eliminating the need for water injection used in a routine EUS case. It would have been challenging to target the vessel if it had been in the fundus.

Gastric NETs are vascular tumors, so bleeding during ESD of a NET is common. Torrential bleeding is rare. In most cases, standard techniques such as coagulation with an electrosurgical knife or a hemostatic forceps and through-the-scope or over-the-scope clips are effective in achieving hemostasis.

However, when the bleeding source cannot be localized, EUS serves as a valuable tool for visualization and targeted intervention. To use EUS in such cases requires significant expertise in therapeutic EUS. Glue injection in the superficial vessel can cause mucosal ischemia, ulceration, and necrosis, which may limit future endotherapy. Therefore, EUS-guided glue injection should be reserved as a last resort but an essential option for hemostasis in cases with severe bleeding and a source that is not visualizable.

Markings were made in a circular fashion around the gastric neuroendocrine tumor.

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