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Acute mesenteric hemorrhage associated with EUS-guided fine needle aspiration.

To the Editor: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is now regarded as a useful entity for the cytologic diagnosis of pancreatic malignancies.1,2 The linear-array echoendoscope allows real time ultrasound visualization of a needle advanced into a lesion and thus allowing FNA (EUS-guided FNA). Previous studies have validated the safety of EUS-FNA for pancreatic lesions. Bleeding, perforation, infection, and pancreatitis have been described. The bleeding is typically minor and occurs in about 4% of EUS-FNA cases. However, mesenteric hemorrhage after EUS-FNA has not been previously reported. A 61-year-old white male presented to us with a 3-week history of jaundice associated with weight loss. Coagulation parameters and a complete blood count were within normal ranges. Aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase were slightly elevated with a total bilirubun level of 14mg/dL. Computed tomography of the abdomen demonstrated a 31 33mm lesion in the pancreatic head. EUS evaluation with a radialscanning and linear-array echoendoscope revealed a 33 35-mm hypoechoic mass in the pancreatic head, abutting the splenoportal confluence. Additionally, EUS revealed a 12-mm hypoechoic malignant appearing celiac lymph node. FNA was first performed of the celiac node with a 22-gauge needle by using a transgastric approach. Color Doppler imaging was used before the needle puncture to avoid vascular structures. The initial aspirate was grossly bloody. Four subsequent aspirates were nonbloody and revealed adequate cellularity. FNA performed on the pancreatic mass was uneventful. The patient was observed for a few hours in the endoscopy unit before discharge and was doing well. Cytologic evaluations of the aspiration specimens of the pancreatic mass and celiac lymph node were consistent with the diagnosis of a poorly differentiated small cell carcinoma. Twelve hours after EUS-FNA, the patient experienced severe upper abdominal pain with presyncopal symptoms. The patient returned to the hospital where he was found to be hypotensive (BP=80/45mm Hg) and tachycardic (heart rate=115 beats/ min). Laboratory data revealed hemoglobin of 6.4 g/dL (hemoglobin 24 h earlier was 11 g/dL). Contrastenhanced computed tomography showed a 11 7 cm mesenteric hematoma extending from the left lobe of the liver to the right lower quadrant. The source of hemorrhage was presumed to be from accidental puncture of a branch of the celiac axis during FNA of the celiac lymph node. The patient was transfused with blood products to improve the anemia. One day after admission, he developed an episode of fever with a temperature of 1011F. Chest x-ray was normal, and blood and urine cultures did not grow out any microorganisms. An infected hematoma was assumed, and the patient was empirically treated with piperacillin/ tazobactam (3.375 g every 6 h intravenously). The patient responded well after 7 days of therapy. Laboratory tests returned to normal levels within 2 weeks. The patient was deemed to have a surgically unresectable pancreatic cancer due to evidence of celiac nodal invasion and referred for palliative chemoradiation. We report a case of EUS-guided FNA of a celiac lymph node associated with a hemodynamically significant mesenteric hemorrhage. To our knowledge, this is the first such report in the literature. EUS-FNA is a useful and safe method to obtain a cytologic diagnosis of gastrointestinal malignancies. The frequency of EUS-FNA–associated complications seems to be around 1.5% to 2.0%. Hemorrhage as a complication of EUS-FNA has been rarely described. Mild intraluminal bleeding has been described in 4% of cases.9 However, the occurrence of a clinically significant hemorrhage as a result of EUS-FNA is extremely rare. In the majority of cases, the hemorrhage is self limited and does not require hospitalization. The underlying mechanism for mesenteric hemorrhage in our case raises the concern of inadvertent mesenteric vessel laceration related to ‘‘wobbling’’ the needle during biopsy. Despite the linear-array echoendoscopes having Doppler capability to identify vascular structures in the path of the needle, vessels may be accidentally traversed during the procedure. The celiac lymph node is in close proximity to the take-off of the celiac trunk, and there is a risk of vascular injury when performing EUS-FNA in this region. In the current case, EUS-FNA of the celiac node was performed only after excluding the presence of vascular structures within the trajectory of the needle, and bleeding occurred after a single needle pass. Total avoidance of this complication may not be possible with currently available instruments and techniques. With the increasing utility of EUS-guided FNA, it is expected that more complications related to this procedure will be seen. A large mesenteric hematoma can act as excellent culture media for bacterial growth and thus lead to a fulminant infection since EUS-FNA is performed under nonsterile conditions. Therefore, patients with these complications should be administered antibiotics when a hematoma is recognized. Most patients who present with a clinically significant hemorrhage after EUS-FNA can be observed. The need to proceed to surgical intervention for this complication has not been reported in the literature. We recommend that the endoscopist should be especially vigilant when performed EUS-FNA is the vicinity of the celiac axis. LETTERS TO THE EDITOR