Sp704 Prototype Forward Viewing Linear Array Echoendoscope for Management of Upper GI Bleeding

Abstract

Real time EUS imaging of submucosal arteries would be an advance in the management of upper GI bleeding, as it may allow for targeting of therapy and assessment of cessation of blood flow post therapy. However, curvilinear array echoendoscopes currently in use are inadequate. The oblique view limits endoscopic imaging and delivery of therapy. We present for the first time, in a human study, the feasibility of visualizing submucosal arteries with, and delivery of guided hemostatic therapy using a prototype forward-viewing echoendoscope. A 58 year old female patient presented with hematemesis, melena and a 4 gram drop in hemoglobin. She was admitted to the intensive care unit, and resuscitated with blood and IV fluid. Endoscopy was performed with a prototype forward-viewing therapeutic echoendoscope, XGIF-UCT160J-AL5; (Olympus Inc, Tokyo, Japan), which has a 90° US scanner with color Doppler, and a 3.7-mm working channel, without an elevator. An actively bleeding Dieulafoy lesion was seen in the post bulbar duodenum. Thermal therapy with a 10Fr heater probe was performed for hemostasis. Despite adequate post-treatment visual appearance, subsurface arterial blood flow was audible with a through-the-scope doppler ultrasound probe. High resolution endosonographic exam demonstrated multiple deep and superficial blood vessels with active blood flow. Superficial blood vessel's of upto 0.8 mm in diameter were seen at a depth of upto 3mm. Additional thermal therapy was applied with the heater probe with simultaneous endoscopic and sonographic visualization. Post treatment, doppler flow was absent at shallow depth, and sonographic exam of the the site demonstrated no superficial blood flow. Real-time sonographic imaging of submucosal blood flow in a bleeding lesion appears feasible with a forward-viewing echoendoscope. Precise targeting of therapy with this echoendoscope is a possibility. This could potentially improve efficacy of hemostasis in GI bleeding, leading to a decrease in re-bleeding rates, and mortality. Larger studies are necessary to delineate efficacy, appropriate indications and limitations of management of GI bleeding with this prototype echoendoscope.