Post written by Radhika Chavan, MD, DNB, FISG, FASGE, from Bharati Vidyapeeth, Katraj, India.

A 38-year woman presented with upper GI bleeding. During evaluation, it was detected she had a large subepithelial lesion in the midbody of the stomach. Further evaluation with EUS revealed a large hypoechoic lesion confined to the submucosa with a large feeding vessel. The patient underwent endoscopic submucosal dissection (ESD) after a multidisciplinary meeting.

Because of the large feeding vessel, severe bleeding was anticipated during ESD. Therefore, to reduce the risk of bleeding during ESD, pre-emptive epinephrine was injected under EUS guidance at the base of the subepithelial lesion near the feeder vessel. A total of 5 mL of diluted epinephrine (1:10,000) was injected at the base with a 19-gauge FNA needle. After injection, instantaneous pallor of the lesion was observed. ESD of the large gastric subepithelial lesion was subsequently completed without bleeding. Histopathological examination showed a neuroendocrine tumor (NET).

This case highlights use of EUS-guided pre-emptive epinephrine injection for a large gastric NET to minimize bleeding risk during ESD.

Gastric NETs are highly vascular, and bleeding during endotherapy is common. Although torrential bleeding is uncommon, it can be life-threatening when it occurs. From our past experience of managing torrential bleeding during gastric NET ESD,¹ we learned the importance of anticipating and preparing for such adverse events. In that case, conventional hemostatic techniques failed because the bleeding source could not be localized, and we had to resort to EUS-guided glue injection to control the situation.

In the present case, given the presence of a large feeder vessel, we adopted the principle that prevention is better than cure. Initially, EUS-guided feeder vessel embolization with glue was considered but avoided because of concerns that glue might hinder subsequent dissection.

Instead, we opted for a pre-emptive EUS-guided epinephrine injection to minimize the risk of bleeding. This strategy proved effective—during ESD, only a few smaller vessels were encountered, and the larger vessels appeared pale and were prophylactically coagulated with hemostatic forceps. The marked reduction in vascularity can be attributed to the vasoconstrictive effect of epinephrine.

Careful preprocedural assessment of vascularity and feeder vessels with EUS can guide preventive strategies. Pre-emptive embolization of a large feeder vessel can be considered prior to ESD to minimize bleeding risk. There are reports of interventional radiologists performing feeder vessel embolization before gastric polyp resections; however, the advantage of using EUS is that it can be performed in the same setting and under real-time imaging intervention can be carried out. EUS enables precise localization of the feeder vessel, making targeted intervention feasible.

Compared with conventional gastroscopic epinephrine injection with a sclerotherapy needle, EUS-guided FNA allows deeper penetration into the lesion’s base, facilitating delivery of epinephrine or other embolizing agents directly into or adjacent to the feeder vessel. This targeted approach increases efficacy in reducing vascularity before dissection. The choice of embolizing agent requires further study to establish safety and efficacy, but epinephrine offers several practical advantages: It is readily available, produces immediate vasoconstriction, and does not interfere with subsequent dissection.

This case underlines the evolving role of EUS not only in diagnosis and guidance but also in expanding therapeutic possibilities in ESD. Although our results are encouraging, further studies are needed to validate the safety, reproducibility, and broader application of this technique.

Pre-emptive EUS-guided epinephrine injection performed at the base into the feeder vessel. A, The feeder vessel was identified on EUS, and adjacent area was targeted with a 19-gauge needle, and diluted epinephrine injection (1:10,000) was administered. B, After epinephrine injection, a significant decrease in Doppler flow was noted. C, Gastroscopic view of the gastric lesion before epinephrine injection. D, Gastroscopic view of the gastric lesion postepinephrine injection, showing the lesion becoming pale.

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1. Chavan R, Nabi Z, Gandhi C. EUS-guided glue injection for managing torrential bleeding during gastric neuroendocrine tumor endoscopic submucosal dissection: sealing the storm. VideoGIE 2024;9:468-71. ↩︎