Submucosal Epinephrine Injection Research Articles

Effect of Nasal Submucosal Injection of Low-concentration Epinephrine on Visual Field Visualization in Endoscopic Sinus Surgery: A Systematic Review and Meta-analysis.

Objective: To determine whether nasal submucosal injection of low-concentration epinephrine improved the surgical field visualization and physician satisfaction compared to placebo or without intervention. Methods: A literature search of PubMed, Scopus, Web of Science, Cochrane library, China National Knowledge Infrastructure, and Wanfang Database was conducted from inception to January 10, 2023. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analyses were performed using Review Manager (RevMan version 5.3; the Cochrane Collaboration). Quality was assessed by 2 reviewers using the Cochrane Risk of Bias Tool. And we used funnel plots to visually assess the risk of publication bias. Results: We included a total of 11 studies with 492 patients, all of which were randomized controlled trials. Among the studies, 4 had a low risk of bias, 4 had a moderate risk of bias, and 3 had a high risk of bias. Five studies reported visual bleeding grade in the surgical field (P = 0.07) and total blood loss (P = 0.16), 8 studies reported preoperative baseline heart rate (P = 0.58) and baseline mean arterial pressure (MAP) (P = 0.78), and 9 studies reported intraoperative heart rate (P = 0.27) and MAP (P = 0.56), which showed no significant differences in these parameters between the 2 groups. None of these outcomes were statistically significant between the epinephrine group and the control group. Conclusion: There is insufficient evidence to support the nasal submucosal application of low-concentration epinephrine to improve surgical field dryness and reduce total surgical bleeding.

EUS-directed transgastric endoscopy for upper gastrointestinal bleeding.

A 64-year-old man who had undergone a Roux-en-Y gastric bypass presented because of massive upper gastrointestinal bleeding. The diagnostic and initial therapeutic approach included an upper-endoscopy and colonoscopy without finding the bleeding source. After blood transfusions and hemodynamic stability was reached, a computed tomography angiography was performed. Finding an active extravasation of contrast in the duodenal bulb. After discussion of options, a EUS-directed transgastric endoscopy was proposed. A linear echoendoscope (GF-UCT180; Olympus America, Center Valley, Pa, USA) was advanced into the gastric pouch. Under US guidance, the excluded stomach was located. Under fluoroscopic and US guidance, the remnant stomach was punctured with a 19-gauge EUS needle. As a safety measure; sterile water, methylene blue, and contrast material were injected. Through endosonographic vision a 15-mm × 10-mm cautery-enhanced, lumen-apposing metal stent (LAMS, Axios; Boston Scientific, Natick, Mass, USA) was inserted [Figure 1] creating a gastrogastric fistula between the pouch and the remnant stomach. A gastroscope (GIF-HQ190, Olympus America) was then inserted, followed by a 12 mm CRE balloon (CRE™ Single-Use WIREGUIDED Balloon Dilator) used for dilatation [Figure 2]. The scope was advanced to the duodenal bulb, finding a Forrest IIa ulcer. Conventional endoscopic treatment was performed with submucosal epinephrine injection and mechanical hemostasis with clips Figure 3. The LAMS was left until it was verified that there was no rebleeding risk. Bariatric surgery modifies patient’s anatomy and physiology, bleeding duodenal ulcer are usually treated with urgent laparotomy or interventional radiology.[1] EUS-directed transgastric procedures may offer a minimally invasive, effective option, with less resource utilization in modified anatomy patients that require endoscopic access to gastric remnant for therapeutic procedures.[2,3] To the best of our knowledge, this was the first edge procedure used as a therapeutic measure for bleeding in patients with modified anatomy.Figure 1: EUS gastro-gastric fistulaFigure 2: LAMS ballon dilatationFigure 3: Conventional endoscopic treatmentDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Submucosal Epinephrine Injection Before Endoscopic Papillectomy: Less is More?

Submucosal Epinephrine Injection Before Endoscopic Papillectomy: Less is More?

Efficacy of Epinephrine Injection in Preventing Post-ERCP Pancreatitis.

Rectal indomethacin or a topical spray of epinephrine to the papilla of Vater has each shown efficacy alone in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We supposed that a submucosal epinephrine injection would be more effective and longer acting than a topical epinephrine spray and therefore would further reduce the incidence of PEP. A retrospective analysis was conducted of 412 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2017 and December 2019. These patients were divided into 2 groups: the indomethacin group and the indomethacin plus the submucosal epinephrine injection group. The incidence rates and severity of PEP, post-ERCP hyperamylasemia, other outcomes, and any other adverse events were compared between the groups. Baseline demographic and clinical characteristics and procedure-related parameters were similar between the 2 groups. The incidence of PEP was 0.4% in the epinephrine group compared with 5.1% in the indomethacin group (P<0.001). Post-ERCP hyperamylasemia occurred in 24.6% of patients in the indomethacin group, whereas 7.6% of patients in the epinephrine group developed this condition; the difference was significant (P<0.001). Postsphincterotomy bleeding occurred in 5 patients, all of whom were in the indomethacin group (P<0.001). Other adverse events, including arrhythmias, acute coronary events, stroke, or hypertension were not significantly different between the 2 groups. Addition of a submucosal epinephrine injection in conjunction with rectal indomethacin significantly reduced the incidence of PEP, post-ERCP hyperamylasemia, and postsphincterotomy bleeding.

Colorectal endoscopic mucosal resection with submucosal injection of epinephrine versus hypertonic saline in patients taking antithrombotic agents: propensity-score-matching analysis

BackgroundEndoscopic mucosal resection (EMR) to remove colon polyps is increasingly common in patients taking antithrombotic agents. The safety of EMR with submucosal saline injection has not been clearly demonstrated in this population.AimsThe present study aimed to evaluate the efficacy and safety of submucosal injection of saline–epinephrine versus hypertonic saline in colorectal EMR of patients taking antithrombotic agents.MethodsThis study enrolled 204 patients taking antithrombotic agents among 995 consecutive patients who underwent colonic EMR from April 2012 to March 2018 at Ureshino Medical Center. Patients were divided into two groups according to the injected solution: saline–epinephrine or hypertonic (10%) saline (n = 102 in each group). Treatment outcomes and adverse events were evaluated in each group and risk factors for immediate and post-EMR bleeding were investigated.ResultsThere were no differences between groups in patient or polyp characteristics. The main antithrombotic agents were low-dose aspirin, warfarin, and clopidogrel. Propensity-score matching created 80 matched pairs. Adjusted comparisons between groups showed similar en bloc resection rates (95.1% with saline–epinephrine vs. 98.0% with hypertonic saline). There were no significant differences in adverse events (immediate EMR bleeding, post-EMR bleeding, perforation, or mortality) between groups. Multivariate analyses revealed that polyp size over 10 mm was associated with an increased risk of immediate EMR bleeding (odds ratio 12.1, 95% confidence interval 2.0–74.0; P = 0.001).ConclusionsTwo tested solutions in colorectal EMR were considered to be both safe and effective in patients taking antithrombotic agents.

Tu1389 CAN PROPHYLACTIC APC REDUCE DELAYED POST-PAPILLECTOMY BLEEDING? A PROSPECTIVE RANDOMIZED MULTICENTER TRIAL

Endoscopic post-papillectomy bleeding occurs in 3 to 20% of cases and delayed bleeding within one week is also problematic. However, there was no definite guideline or consensus for prevention or reduction of delayed post-papillectomy bleeding. Submucosal injection of dilute epinephrine before endoscopic papillectomy may not aid in reducing the risk of delayed bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to prevent or reduce delayed post-papillectomy bleeding. A prospective randomized study was performed at six tertiary referral centers in Korea. Patients with benign papillary tumors were enrolled from January 2015 to August 2017 and were randomized to either the prophylactic APC group or non-APC group. Endoscopic papillectomy was performed using a conventional snaring papillectomy method. Then, APC on the resection margin was performed in the prophylactic APC group. On the day after papillectomy, all patients underwent follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up with duodenoscopy at 1 month later. The main outcome measures were delayed (>24 h) post-papillectomy bleeding rate and remnant tissue ablation effects. In total, 48 patients underwent endoscopic papillectomy. Delayed bleeding rates in the prophylactic APC and non-APC groups were 33.3% (8/24) and 16.7% (4/24), respectively (p=0.336). Tumor persistence at 1 month did not differ between the two groups (12.5% vs. 8.3%, p=0.628). The mean tumor length and width were 11 and 12 mm in the prophylactic APC group, and 13.6 and 12.7 mm in the non-APC group. En-bloc resection rates in the prophylactic APC and non-APC groups were 83.3% (20/24) and 95.8% (23/24), respectively. Positive resection margin rates in the prophylactic APC and non-APC groups were 66.7% (16/24) and 33.3% (8/24), respectively (p=0.076). Post-procedure pancreatitis rates were 20.7% (5/24) in the prophylactic APC and 37.5% (9/24) in the non-APC groups, respectively (p=0.295). The severity of pancreatitis did not differ between the two groups. There were no procedure-related mortalities or serious complications. Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation. The prophylactic APC group seemed to have a higher tendency of delayed post-papillectomy bleeding without statistical difference and might be also ineffective on remnant tumor ablation during short-term follow-up.

Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies.

BackgroundBleeding is the most common major complication following colonoscopic polypectomy. The purpose of this study is to evaluate whether submucosal epinephrine injections could prevent the occurrence of postpolypectomy bleeding.MethodThe dataset was defined by searching PubMed, EMBASE, Google Scholar, and the Cochrane database for appropriate randomized controlled studies published before April 2015. A meta-analysis was conducted to investigate the preventative effect of submucosal epinephrine injection for overall, early, and delayed postpolypectomy bleeding.ResultsThe final analysis examined the findings of six studies, with data from 1388 patients. The results demonstrated that prophylactic treatment with epinephrine injection significantly reduced the occurrence of overall (OR = 0.38, 95% CI: 0.21, 0.66; p = 0.0006) and early bleeding (OR = 0.38, 95% CI: 0.20, 0.69; p = 0.002). However, for delayed bleeding complications, epinephrine injections were not found to be any more effective than treatment with saline injection or no injection (OR = 0.45, 95% CI: 0.11, 1.81; p = 0.26). Moreover, for patients with polyps larger than 20 mm, mechanical hemostasis devices (endoloops or clips) were found to be more effective than epinephrine injection in preventing overall bleeding (OR = 0.33, 95% CI: 0.13, 0.87; p = 0.03) and early bleeding (OR = 0.29, 95% CI: 0.08, 1.02; p = 0.05). This was not established for delayed bleeding.ConclusionThe routine use of prophylaxis submucosal epinephrine injection is safe and beneficial preventing postpolypectomy bleeding.

Peer review report 1 on “Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies”

Peer review report 1 on “Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies”

Peer review report 2 on “Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies”

Peer review report 2 on “Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: A meta-analysis of randomized controlled studies”

Bleeding Duodenal Ulcer Successfully Managed with an Over-the-Scope-Clip

A 70 year-old woman was admitted for right upper quadrant pain with radiation to the back, anorexia and vomiting. Ultrasound abdomen was notable for a dilated CBD to 12mm, thickened gallbladder wall with sludge but no stones and her liver chemistries were normal. HIDA scan and MRCP were also unremarkable. On further inquiry the patient reported 7-month history of abdominal pain and had never previously had an upper endoscopy. The EGD was notable for antral erosions and a pre-pyloric 5mm clean-based ulcer in the stomach. The duodenal bulb was notable for a large 2cm posterior ulcer with large adherent clot with active bleeding (Fig. 1A). The distal duodenum demonstrated no bleeding. The endoscope was removed from the patient and an over-the-scope-clip (OTSC) or “bear claw” was applied to its distal end and the endoscope was reintroduced into the patient's abdomen. Submucosal injection of epinephrine 1:10,000 was made around the lesion with effective mucosal blanching. Then a combination of irrigation and the clear cap was used to remove most of the clot. Then the 12-3 gc OTSC was placed revealing a visible vessel centered within the bear claw (Fig. 1B), effective hemostasis was achieved. A second look EGD three days later and repeat procedure at 4 weeks demonstrated healing of the ulcer (Fig 1C,D). At the last visit an EUS was performed revealing a 10mm CBD with smooth taper to the ampulla, without choledocholithiasis and a 5mm gallbladder polyp. Gastric biopsies for helicobacter pylori were negative. The patient's pain had resolved by that time. The OTSC was designed to ensnare a large amount of tissue to facilitate closure of perforations, fistulas and anastomotic leaks. However, the nitinol made clip has seen its use expand to hemostasis and stent fixation. Posterior duodenal bulb ulcers can present a challenge for the endoscopist. The position may not provide adequate access for management with endoscopic clips or the heater probe. Clips may fall off, injuring the culprit vessel and thereby initiating a cascade of further GI bleeding. In this case, the OTSC easily achieved hemostasis. In addition to acid suppression therapy the OTSC provided adequate ulcer healing in a few days with complete resolution of the duodenal ulcer at 4 weeks. This case demonstrates the expanding role of OTSCs in the gastroenterologist's management of bleeding ulcers.Figure 1

Polidocanol injection decreases the bleeding rate after colon polypectomy: a propensity score analysis

EMR is the standard of care for the resection of large polyps. To compare the efficacy and safety profile of submucosal polidocanol injection with epinephrine-saline solution injection for colon polypectomy with a diathermic snare. After 1-to-1 propensity score caliper matching, comparison of submucosal epinephrine injection was performed with polidocanol injection. Endoscopic suite at the University of Foggia between 2005 and 2014. Of 711 patients who underwent endoscopic resection of colon sessile polyps 20 mm or larger, 612 were analyzed after matching. Submucosal epinephrine injection in 306 patients and polidocanol injection in 306 patients. Univariate and multivariate logistic regression models aimed at identifying independent predictors of postpolypectomy bleeding (PPB). The 2 groups presented similar baseline clinical parameters and lesion characteristics. All patients had a single polyp 20 mm or larger; the median size was 32 mm (interquartile range [IQR], 25-38) in the polidocanol group and 32 (IQR, 24-38) in the epinephrine group (P=.7). Polidocanol was more effective in preventing both immediate and delayed PPB (P<.001 and P=.003, respectively), and its efficacy was confirmed in almost all of the subgroups, regardless of polyp size and histology. Postprocedure perforation was observed in 2 patients (0.3%), both in the epinephrine group (P=.49). The 2 groups did not differ in the number of snare resections of lesions or the procedure duration (P=.24 and .6, respectively). Absence of randomization. The submucosal injection of polidocanol for colon EMR is effective and significantly lowers the PPB rate.

Intramural duodenal hematoma after submucosal injection of epinephrine for a bleeding ulcer: case report and review

We present a case of intramural duodenal hematoma as a complication of endoscopic therapy for a bleeding duodenal ulcer in an adult patient with no evidence of other pathologies. A 18-year-old man was admitted in emergency room with gastrointestinal bleeding manifested by melena. Previous medical history revealed that he had endoscopic sclerotherapy for bleeding duodenal ulcer 5 months before. Endoscopy revealed a Forrest 2a ulcer in the duodenal bulb and sclerotherapy was performed by injecting 10 ml of 0.2% epinephrine and 20 ml of Na- Cl 0.9% solution. Upper occlusion's signs appeared 36 hours after the procedure. The hematoma, that was identified by endoscopy and confirmed by MRI and CT scan of the abdomen, caused transient duodenal obstruction. Combined conservative management with nasogastric tube and total parenteral nutrition resulted in reduction of obstructive symptoms within 4 weeks.

Gastric ischemia after epinephrine injection in a patient with liver cirrhosis

Endoscopic epinephrine injection is relatively easy, quick and inexpensive. Furthermore, it has a low rate of complications, and it is widely used for the management of nonvariceal upper gastrointestinal bleeding. There have been several case reports of gastric ischemia after endoscopic injection therapy. Inadvertent intra-arterial injection may result in either spasm or thrombosis, leading to subsequent tissue ischemia or necrosis, although the stomach has a rich vascular supply and the vascular reserve of the intramural anastomosis. In addition to endoscopic injection therapy, smoking, hypertension and atherosclerosis are risk factors of gastric ischemia. We report a case of gastric ischemia after submucosal epinephrine injection in a 51-year-old woman with hypertension and liver cirrhosis.

A Case of Takotsubo Cardiomyopathy due to Submucosal Epinephrine Injection during Endoscopic Sinus Surgery

Epinephrine은 혈관 수축 작용이 있어 이비인후과 영역의 수술에서 출혈을 줄이고, 국소 마취제의 전신적 흡수를 막기 위해 국소 침윤 또는 점막 도포의 방법으로 널리 사용되고 있 다. 그러나 epinephrine은 과량을 사용하거나 혈관에 직접 주 사하면 치명적인 심계항진, 폐부종, 심정지 등의 심각한 부작 용을 초래할 수 있다. 그런데 수술 중 허용 범위내의 epinephrine을 국소적으로 사용한 후 급성 심근경색증과 유사한 양 상을 나타내는 Takotsubo 심근병증이 드물게 보고되고 있다. 이 질환은 급성기에 응급 처치가 제대로 이루어지면 정상 상 태로 회복이 가능하지만 치료시기를 놓치면 폐부종, 심정지까 지 일으킬 수 있다. 저자들은 만성 부비동염으로 내원한 56세 남자 환자의 부비동 내시경 수술 중 허용 범위 안의 epinephrine을 비점막하 국소 주사 후 발생한 가역적인 Takotsubo 심 근병증 1예를 경험하였기에 문헌 고찰과 함께 보고하는 바이다.

Leserbrief

Whether the treatment of benign ampullary tumors should be performed as transduodenal surgical excision or endoscopic ampullectomy depends on the size and spread of the tumor. In this videopaper we report technical hints on the surgical resection. Surgical resection is indicated for benign ampullary lesions if endoscopic resection is not possible. In addition, local resection can be performed in cases with high risk of malignancy or in a palliative intention. The duodenum is mobilized by the Kocher maneuver. It is recommendable to perform a cholecystectomy to introduce a flexible catheter antegrade into the common bile duct through the cystic duct for identification of the papilla of Vater by digital palpation. An anterolateral oblique duodenotomy is made and thereby the tumor of the papilla is exposed, followed by a submucosal injection of epinephrine to elevate the tumor. Afterwards a 5-10 mm margin is scored circumferentially in the mucosa around the adenoma. The extent of the excision is based on the preoperative and intraoperative assessment; a submucosal or full thickness (for transmural lesions) excision can be performed. After submucosal excision the mucosa of the ampulla is approximated to the mucosa of the duodenum. In cases with full thickness ampullectomy the borders of the pancreatic and bile duct are approximated and then the entire complex is sutured to the full wall of the duodenum. Furthermore in some cases with extensive resection a separate reconstruction of the pancreatic and bile duct may be required. A terminal assessment of the ductal patency is imperative. The duodenectomy is closed and a paraduodenal drain is placed. Transduodenal resection of periampullary tumors can be technically demanding, but provides a stage-adapted treatment modality for benign and premalignant lesions of the papilla of Vater.

Transduodenale Papillenresektion

Whether the treatment of benign ampullary tumors should be performed as transduodenal surgical excision or endoscopic ampullectomy depends on the size and spread of the tumor. In this videopaper we report technical hints on the surgical resection. Surgical resection is indicated for benign ampullary lesions if endoscopic resection is not possible. In addition, local resection can be performed in cases with high risk of malignancy or in a palliative intention. The duodenum is mobilized by the Kocher maneuver. It is recommendable to perform a cholecystectomy to introduce a flexible catheter antegrade into the common bile duct through the cystic duct for identification of the papilla of Vater by digital palpation. An anterolateral oblique duodenotomy is made and thereby the tumor of the papilla is exposed, followed by a submucosal injection of epinephrine to elevate the tumor. Afterwards a 5-10 mm margin is scored circumferentially in the mucosa around the adenoma. The extent of the excision is based on the preoperative and intraoperative assessment; a submucosal or full thickness (for transmural lesions) excision can be performed. After submucosal excision the mucosa of the ampulla is approximated to the mucosa of the duodenum. In cases with full thickness ampullectomy the borders of the pancreatic and bile duct are approximated and then the entire complex is sutured to the full wall of the duodenum. Furthermore in some cases with extensive resection a separate reconstruction of the pancreatic and bile duct may be required. A terminal assessment of the ductal patency is imperative. The duodenectomy is closed and a paraduodenal drain is placed. Transduodenal resection of periampullary tumors can be technically demanding, but provides a stage-adapted treatment modality for benign and premalignant lesions of the papilla of Vater.

Hemodynamics after endoscopic submucosal injection of epinephrine in a porcine model

Endoscopic submucosal injection of epinephrine may cause systemic effects on the cardiovascular system. The aim of this experimental study was to assess systemic hemodynamic changes after submucosal injection of epinephrine during upper gastrointestinal endoscopy in a porcine model. Measurements were taken from 12 pigs under general anesthesia. During gastroscopy 5 mL of normal saline, and 2.5 mL and 5 mL of epinephrine (1:10,000) were injected into the submucosal layers of the gastric antrum, corpus, and distal esophagus. After each injection, the cardiac index and global end diastolic volume index (GEDVI, reflecting preload) were measured every 3 minutes by transpulmonary thermodilution for a minimum of 12 minutes. The following parameters were also recorded: heart rate, mean arterial pressure (MAP), and systemic vascular resistance index (SVRI, reflecting afterload). Significant hemodynamic changes were observed after submucosal injection of epinephrine into the esophagus, including heart rate (maximum + 4 %) and MAP (maximum - 4%) after injection of 2.5 mL epinephrine, and stronger changes in heart rate (maximum +13%), cardiac index (maximum +21%), MAP (maximum -4%), and SVRI (maximum -12%) after the injection of 5 mL epinephrine. After submucosal injection of epinephrine into the gastric antrum and corpus, hemodynamic effects were less evident. Here significant changes were observed in heart rate (maximum +3%), MAP (maximum -2%), cardiac index (maximum +7%), and SVRI (maximum -8%) only after the injection of 5 mL epinephrine into the antrum. Endoscopic submucosal injection of epinephrine is associated with changes in systemic hemodynamic parameters, especially when performed in the esophagus, and the procedure might therefore induce harmful side effects.

Myocardial Infarction Thought to be Provoked by Local Epinephrine Injection During Endoscopic Submucosal Dissection

Due to its hemostatic effect, local epinephrine has been used to minimize mucosal bleeding during endoscopic submucosal dissection (ESD), but its clinical benefit remains unclear. On the other hand, several adverse events deemed to be caused by epinephrine have been observed during ESD. A 73-year-old woman developed myocardial infarction after ESD for a large rectal adenoma, and an 80-year-old woman developed abrupt chest tightness during ESD. In both patients, changes on electrocardiogram and elevated cardiac markers provided evidence of myocardial ischemia. The patients were transferred to the cardiac care unit and recovered completely. Up to our knowledge this is the first report of myocardial infarction thought to be provoked by submucosal epinephrine injection during ESD.KeywordsAdenoma; Colon; Endoscopic surgical procedure; Epinephrine; Myocardial infarction

Initial evaluation of a novel, prototype, forward-viewing echoendoscope in a porcine arterial bleeding model (with video)

Real-time visualization of submucosal arterial flow at the base of an ulcer might improve endoscopic hemostasis by permitting more accurate assessment of the artery, precise targeting of therapy, and confirmation of vessel ablation. To evaluate the utility of a novel, forward-viewing echoendoscope in identifying bleeding submucosal arteries, guiding hemostatic therapy, and confirming cessation of flow through treated vessels. In 7 pigs, a previously described porcine model for peptic ulcer hemorrhage was created by isolating the gastroepiploic and/or short gastric artery and tunneling it into the subserosal space at laparotomy. Animal research facility. The prototype endoscope was used to image submucosal arterial flow. EUS guidance was then used to deliver endoscopic hemostatic therapy and assess treatment adequacy. Identification of the target submucosal artery and successful delivery of EUS-guided endoscopic therapy, evidenced by cessation of Doppler flow through the target vessel. Tunneled arteries were visualized endosonographically in all 7 cases. EUS-guided submucosal injection of epinephrine was successful in 2 of 2 cases. EUS-guided delivery of thermal hemostatic therapy was successful in 2 of 4 cases. Absence of flow through treated vessels was confirmed in cases in which EUS-guided therapy was successfully delivered. Acute animal model. Proof of principle experiments in a porcine peptic ulcer hemorrhage model suggest that real-time sonographic imaging of submucosal arteries is feasible with a forward-viewing echoendoscope, and guided hemostatic therapy can be delivered.

Cardiac arrest induced by submucosal injection of epinephrine in a patient with variant angina

This case report describes a 35-year old male who experienced ventricular tachycardia induced by intramucosal injection of epinephrine (1:100,000). Under general anaesthesia with desflurane inhalation, 1.5% lidocaine containing 1:100,000 epinephrine was injected into the nasal mucosa for septoplasty. ST segment elevation and QRS widening occurred after 10 minutes and progressed to pulseless ventricular tachycardia. A sinus rhythm was restored after cardiopulmonary resuscitation with electrical cardioversion. The cardiac enzymes were significantly elevated after the event. Exercise-stress testing and coronary angiography were normal. However, an injection of acetylcholine into the coronary artery provoked vasospasm in the left anterior descending and circumflex arteries. This case illustrates an unusual response to low dose epinephrine with cardiac arrest induced in a patient with undiagnosed variant angina.