Profuse bleeding from an endobronchial biopsy is of concern to the bronchoscopist. In the following brief report we describe a new technique, endobronchial intralesional epinephrine injection, which can effectively control this complication.
A 40-year old man presented to the hospital with right-sided chest pain and a cough of 4-weeks' duration. The chest pain did not increase with either cough or deep inspiration. He had a weight loss of 6.8 kg over several months and a 20-pack-year smoking history. Vital signs were within normal limits. Physical examination of the lungs revealed dullness to percussion and decreased breath sounds in the right side of the chest. Mild facial swelling was also noted. Complete blood count, coagulogram, blood urea nitrogen, creatinine, and electrolytes were normal. A large right hilar mass was evident on the chest radiograph. Thoracic computed tomography with and without contrast revealed a 12-cm soft-tissue mass with calcification of its lateral and posterior edges (Fig. 1). The mass had a lobular contour in the right paratracheal area. Also noted were small bilateral pleural effusions.
Clinical diagnosis of a right lung mass with superior vena cava syndrome was made. Flexible bronchoscopy was performed and revealed a fleshy growth that completely occluded the right upper lobe bronchus. There was also incomplete extrinsic compression at the right middle lobe bronchus, and at the superior and medial segments of the right lower lobe (Fig. 2). Bronchoscopic examination of the left lung was normal. Endobronchial biopsy specimens were taken from the fleshy growth. Active hemorrhage occurred unexpectedly from the lesion after the second endobronchial biopsy was acquired.
Bronchial wash with normal saline was not associated with cessation of bleeding nor was intrabronchial epinephrine any more effective. Needle injection at the base of the lesion with 5 mL epinephrine solution (1 mL epinephrine 1:1,000 mixed in 19 mL normal saline) was accomplished through a 22-guage transbronchial cytology needle (Mill-Rose Laboratories Inc., Mentor, OH, USA). This resulted in bleeding cessation. Blood loss was approximately 100 mL. The patient remained stable and did not have any episodes of notable hemoptysis after the procedure. Vital signs were stable throughout the recovery period. The pathology of the biopsy revealed malignant lymphoblastic lymphoma. Computed tomography of the abdomen revealed small lymph nodes in the retroperitoneal area. The patient was started on chemotherapy for malignant lymphoma.
To our knowledge, there are no reports in the literature regarding intralesional epinephrine injection for a bleeding endobronchial tumor. Reported bleeding complications during flexible bronchoscopy have ranged from less than 1% to more than 20%, depending on the criteria used to define marked bleeding and the patients studied. 1,2 Most of the reports in the literature did not distinguish transbronchial bleeding from endobronchial bleeding. In one detailed study, the authors reviewed 6,969 flexible bronchoscopies performed over 9 years at their institution. 1 Clinically remarkable bleeding occurred in 58 patients (0.83% of total patients and 1.9% of all brush/biopsies).
Seventeen of these bleeding episodes were secondary to endobronchial biopsy. Profuse bleeding, defined by the authors as bleeding of more than 100 mL, occurred in only 3 of these 17 patients. However, the total number of patients in the subgroup that underwent transbronchial biopsy was not reported. Increased risk of bleeding has been associated with preexisting hemoptysis, coagulopathy, and following brushing or biopsy of endobronchial tumors. Some endobronchial tumors, such as bronchial carcinoid tumors, may develop blood vessels at the surface that can be injured and bleed after flexible bronchoscopy. However, this is not a contraindication to biopsy.
Options reported in the literature for the initial treatment of bleeding during flexible bronchoscopy include iced saline lavage and endobronchial vasoactive drug administration. Further treatment options include balloon tamponade, fibrin glue application, Carlens tube insertion, laser therapy, bronchial artery embolization, and surgery. Iced saline lavage and vasoactive drug administration have been useful in mild bleeding. Vasoactive drugs have been used either endobronchially or systemically, including epinephrine, pitressin, and glypressin. 3,4 Of all the vasoactive agents, epinephrine is the most commonly used. The major pulmonary and bronchoscopy textbooks do not describe intralesional injection of epinephrine to control bleeding.
In upper gastrointestinal endoscopy for bleeding peptic ulcer, intralesional epinephrine injection, alone or in combination with other techniques, at the bleeding site has been used with good results. 5,6 The mechanism of bleeding control of intralesional injection of epinephrine is believed to be through a vasoconstrictive effect on local blood vessels. However, a local tamponade effect may play a major role as well. The increased pressure caused by injecting fluid within the base of the tumor exerts a pressure on the blood vessels that supply the tumor. This pressure would then attenuate the blood flow triggered by the forceps biopsy and lead to cessation of bleeding. Lai et al. 7 randomized 52 patients with bleeding peptic ulcers to receive endoscopic injection therapy with either epinephrine or distilled water and found that local tamponade with distilled water injection was as effective as epinephrine solution injection in controlling the bleeding.
In our patient, the bleeding after endobronchial biopsy did not respond to the initial lavage and epinephrine instillation through the flexible bronchoscope. Intralesional epinephrine injection at the base of the endobronchial lesion using a transbronchial cytology needle resulted in immediate bleeding cessation without any serious complication. We have subsequently used this technique in another patient with similar good results.
In conclusion, this procedure appears to be simple and safe. Intralesional epinephrine injection may be considered a treatment option for patients with endobronchial bleeding after biopsy of an endobronchial tumor.
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