Modified endoscopic vacuum therapy for duodenal hemorrhage in patients with severe acute respiratory syndrome coronavirus 2

 

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The use of extracorporeal membrane oxygenation is eventually needed in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. Hemorrhage is a frequent complication in these patients, including gastrointestinal bleeding, mainly caused by increased inflammatory state, hyperfibrinolysis, coagulopathy, platelet dysfunction, endotheliitis, anticoagulant use, thrombocytopenia, and the extracorporeal membrane oxygenation non-pulsatile blood flow [2] [3]. The duodenum is the most affected organ, probably due to the higher exposure to biliopancreatic secretion associated with reduction in gastrointestinal motility and perfusion ([Fig. 1]). In most cases, there is diffuse bleeding usually refractory to conventional endoscopic hemostatic therapies. Therefore, we present the first reports of a novel mechanism-based therapy for these critically ill patients. Such therapy is based on the use of endoscopic vacuum therapy that promotes deformation at the cytoskeletal level, exudate control, increased angiogenesis, and reduces aggressive mucosal factors such as gastric and biliopancreatic secretions [4] [5]. Thus, it treats vascular fragility associated with endotheliitis that is associated with gastrointestinal bleeding in these patients ([Fig. 2]). A modified endoscopic vacuum therapy using a triple-lumen tube to allow for nutrition and drainage with a single tube through the nares is used, as previously described ([Fig. 3], [Fig. 4]) [5].

Initial esophagogastroduodenoscopy (EGD) typically demonstrated duodenal villous atrophy associated with diffuse bleeding, including active ulcers and visible vessels, which were refractory to conventional endoscopic hemostatic therapies, including hemostatic powder. After endoscopic vacuum therapy placement, all patients were hemodynamically stable within 4–7 days, with no signs of gastrointestinal bleeding. Follow-up EGD demonstrated a completely healed mucosa with no signs of villous atrophy or bleeding ([Video 1]).

Video 1 Modified endoscopic vacuum therapy for the treatment of duodenal hemorrhage in critically ill patients: a simple approach for a complex condition.

In our experience, this technique is associated with high technical and clinical success rates, allowing early enteral nutrition, with no adverse events and a low rate of rebleeding after endoscopic vacuum therapy removal. After the successful use of this approach in refractory cases, we no longer offer conventional endoscopic hemostatic therapies for patients with diffuse gastrointestinal bleeding associated with SARS-CoV-2 on extracorporeal membrane oxygenation, reducing the need for multiple endoscopic procedures and transfusions.

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Publication History

Article published online:
13 May 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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