Local Injection of Fluid Gelatin Under Contrast-Enhanced Ultrasound Guidance for Treating Active Bleeding From the Inferior Epigastric Artery: A Case Report

Abstract

Patient: Male, 62-year-old

Final Diagnosis: Active bleeding from the inferior epigastric artery

Symptoms: Severe abdominal distension

Clinical Procedure: —

Specialty: Radiology

Objective: Unusual clinical course

Background

Injury to the inferior epigastric artery is a major complication of abdominal puncture, and continuous active bleeding from this artery can lead to hemorrhagic shock. Several studies have reported the use of contrast-enhanced ultrasound (CEUS) to diagnose active bleeding in parenchymal organs. Fluid gelatin is a new hemostatic material that can be injected into the bleeding site by using a puncture needle under the precise guidance of CEUS, which enables the implementation of local minimally invasive and appropriate hemostatic treatment. Here, we report the case of a patient in whom CEUS was used to accurately locate the bleeding site before surgery and guide local injection of fluid gelatin with a puncture needle to successfully achieve nonsurgical treatment of hemostasis.

Case Report

A 62-year-old man with post-hepatitis B cirrhosis underwent a successful liver transplant surgery. After surgery, abdominal puncture and drainage were performed because of a large amount of peritoneal effusion due to nephrotic syndrome. The drainage fluid was bright red bloody liquid. CEUS revealed many contrast agent microbubbles extravasating from the inferior epigastric artery into peritoneal effusion along the abdominal puncture tract. Surgical suturing and applying a compression bandage failed to achieve satisfactory results. After receiving the patient’s consent, thrombin and hemostatic glue were injected locally under the guidance of CEUS. Finally, hemostasis was successfully achieved.

Conclusions

CEUS-guided injection of fluid gelatin is a safe and effective treatment method and could serve as an effective measure for nonsurgical treatment and postoperative supplementary treatment of active bleeding from the inferior epigastric artery.

Introduction

A large amount of ascites causes an increase in the intra-abdominal pressure and long-term compression of the kidneys, which affects renal venous return and leads to insufficient blood supply to renal arteries, resulting in renal impairment. This condition is often accompanied by dyspnea, spontaneous peritonitis, and circulatory disorders. Timely drainage of ascites through abdominal puncture can effectively reduce the risk of these complications [1]. Abdominal puncture can easily cause vascular damage and bleeding because of the superficial location of the inferior epigastric artery. The incidence of injury specifically to the inferior epigastric artery is 0.2–2% of all laparoscopic surgeries. The proportion of abdominal wall vascular injuries in gynecological laparoscopic surgeries is 0.01%. A meta-analysis of literature on complications related to abdominal puncture-associated hemorrhage revealed that among patients who underwent surgery or transcatheter intervention due to severe bleeding, 58% of hemorrhages originated from the inferior epigastric artery or its branches [2–4]. Bleeding after inferior epigastric artery injury cannot easily be restrained because of the weak rectus abdominis muscle [5]. Consequently, it causes massive hematomas or even pseudoaneurysms, which can endanger the patient’s life in severe cases.

Case Report

A 62-year-old male patient underwent allogeneic modified piggyback liver transplantation in our hospital 10 months ago for treating decompensated liver cirrhosis after hepatitis B. Following the surgery, his liver function recovered well; however, recurrent bilateral lower-limb edema and decreased urine output occurred. A renal puncture biopsy was performed, and pathological examination showed type I membranoproliferative glomerulonephritis (MPGN). The patient was diagnosed with nephrotic syndrome and type I MPGN. He was then hospitalized for treatment of general edema and severe abdominal distension.

Physical examination revealed the following findings: body temperature, 36.4°C; pulse rate, 78 beats/min; heart rate, 18 beats/min; and blood pressure, 223/87 mmHg. The patient showed no signs of cough or sputum, chills, fever, abdominal pain, or any other discomfort. His mental state, appetite, and sleep were good, with normal bowel movements. No abnormalities were detected in the heart and lungs. The abdomen was flat and soft, with no varicose veins, intestinal patterns, or gastric peristaltic waves. There was no tenderness or rebound tenderness. On the same day, under ultrasound guidance, an abdominal paracentesis and drainage procedure was performed, yielding 1100 mL of pale red ascitic fluid. The puncture procedure was as follows: (1) a point at the lateral one-third of the line connecting the right anterior superior iliac spine and the umbilicus was selected as the puncture site; (2) the puncture site was disinfected, and local anesthesia was administered; (3) under ultrasound guidance, the puncture needle was inserted into the abdominal cavity (single-step). Once entry into the abdominal cavity was confirmed, a guidewire was introduced through the puncture needle; (4) the puncture needle was removed, and a catheter was inserted over the guidewire, secured within the abdominal cavity, and connected to an external drainage tube; (5) the abdominal puncture catheter was fixed at the desired position, the guidewire was withdrawn, and the external end of the drainage tube was attached to a drainage bag.

The color of the drainage fluid from the indwelling catheter for peritoneal effusion gradually changed from light red to bright red, and the hemoglobin level showed a progressive decline. Despite several blood transfusions, the indices continued to show a declining trend, and the hemoglobin level decreased to as low as 41 g/L. The patient refused to undergo nephrotoxic contrast agent-related tests because of the potential for increased liver and kidney burden from imaging tests such as digital subtraction angiography. Instead, he opted to undergo contrast-enhanced ultrasound (CEUS). CEUS was performed as follows: 1.0 mL of the contrast agent SonoVue^® suspension was injected through the median vein of the elbow, and 5 mL of normal saline was then injected to flush the trocar. A timer was started, and dynamic images were acquired. The key observation indicators were as follows: contrast agent development in the abdominal puncture channel; presence or absence of contrast development in the dark area of the effusion; and the source, phase, speed, and range of contrast agent extravasation. This procedure was repeated several times after the bleeding site was preliminarily determined. CEUS revealed that the contrast agent first entered the abdominal cavity along the drainage tube in the abdominal wall puncture channel and then rapidly entered peritoneal effusion in a linear manner (Figure 1). Continuous observation showed “intermittent” fluttering of contrast agent bubbles in the local effusion, and the course of the inferior epigastric artery was observed next to the puncture channel. A diagnosis of active bleeding after injury to the inferior epigastric artery was made based on CEUS findings. Diagnostic abdominal puncture showed no blood coagulation. Emergency laparoscopic surgery revealed continuous bleeding from the puncture hole. The puncture channel was sutured during the operation. The color of the drainage fluid remained unchanged after surgery, and the hemoglobin level continued to decrease. Debridement and suturing procedures under local anesthesia revealed active bleeding from the laparoscopic puncture hole. Screening was performed for a complete set of coagulation factors to find the cause of recurrent bleeding, and the patient was confirmed to have coagulation factor XII deficiency. Abdominal compression bandaging and transabdominal wall suturing of the bleeding artery failed to achieve complete hemostasis. After receiving the patient’s consent, local injection of fluid gelatin under CEUS guidance was planned to treat active bleeding from the inferior epigastric artery. The surgical procedure was as follows: first, CEUS was conducted to determine the location and extent of active bleeding. The optimal needle route was selected, and local anesthesia was performed. Under CEUS guidance, an 18-G PTC needle was punctured into the contrast agent overflow area, and 0.4–0.6 mL of snake venom thrombin (0.5 kU/mL) was injected through the PTC needle. Finally, the fluid gelatin suspension was injected into the active bleeding site (Video 1). Specifically, 3–5 mL of the suspension was injected locally, and a small amount of the suspension was injected along the needle path during the needle withdrawal process to close the path. After injection, a mass-like hyperechoic aggregation was observed at the original bleeding site. On the following day, the drainage fluid of the abdominal effusion turned yellow and transparent. Notably, the hemoglobin level remained stable even in the absence of blood transfusion. The patient’s preoperative hemoglobin level was 66 g/L, plasma thrombin time was 12.8 s, and activated partial thromboplastin time (APTT) was 24.7 s. Postoperatively, the patient’s hemoglobin level improved to 90 g/L, with plasma thrombin time and APTT of 12.6 and 28.1 s, respectively, thus confirming improvement as compared to preoperative levels. There was no sign of contrast agent spillage when CEUS was performed again at the puncture channel. A filling defect of the contrast agent was observed at the original bleeding site (Figure 2). The patient ultimately recovered and was discharged.

Figure 1.

The contrast agent first entered the abdominal cavity along the drainage tube and then rapidly entered peritoneal effusion (green arrow) in a linear manner (red arrow), followed by entry into the anterior abdominal wall (yellow arrow). Contrast-enhanced ultrasound vs grayscale imaging, (A) Contrast-enhanced ultrasound (CEUS) imaging mode; (B) Conventional grayscale imaging mode.

Video 1.

Fluid gelatin suspension was injected through a puncture needle (red arrow) into the bleeding site.

Figure 2.

A filling defect (red arrow) of the contrast agent occurred at the original bleeding site. Contrast-enhanced ultrasound vs grayscale imaging, (A) Contrast-enhanced ultrasound (CEUS) imaging mode, (B) Conventional grayscale imaging mode.

Discussion

In the present case, we conducted interventional treatment of active bleeding from the inferior epigastric artery through CEUS-guided local injection of fluid gelatin and evaluated its postoperative efficacy. CEUS can clearly show the location and speed of active bleeding from the inferior epigastric artery, thereby providing valuable information for further treatment and a strong basis for determining whether laparotomy should be performed and the optimum surgical method. A successful treatment with local injection of fluid gelatin prevents the spillage of the contrast agent, suggesting that the bleeding has stopped. If CEUS still shows active bleeding even after treatment, the above procedure can be repeated for further treatment without any negative effects. Therefore, CEUS can be used not only as a rapid and effective method for diagnosing active bleeding but also as a modality for evaluating the efficacy of treating active bleeding [6]. It can also be utilized for the post-treatment follow-up of patients with active bleeding to ensure that there is no risk of recurrence of bleeding.

The choice of treatment plans mainly depends on the patient’s hemodynamic stability and whether there is persistent active bleeding. If the patient has hemodynamic disorders with active bleeding, general conservative treatment may not be effective in controlling disease progression. Instead, relevant open surgeries such as vascular ligation, ultrasound-guided hemostatic drug injection, and percutaneous arterial embolization should be performed. The preferred clinical method is interventional embolization, a safe and minimally invasive therapy that can rapidly control disease progression, with a high success rate [7].

CEUS is a pure blood pool imaging modality in which the contrast agent microbubbles cannot penetrate the normal blood vessel wall. Active bleeding is diagnosed in cases where contrast agent development is observed outside normal blood vessels [8]. The specificity and sensitivity of CEUS are comparable to those of CT examination [9]. CEUS can effectively visualize the trauma site, bleeding focus, and surrounding structures, and enable assessment of hematoma size [10]. The manifestation of active bleeding after injury to the inferior epigastric artery in CEUS is characterized by the extravasation of contrast agent microbubbles from the inferior epigastric artery and their discharge into peritoneal effusion along the puncture channel.

A minimally invasive intervention to control hemostasis involves the introduction of catheters or instruments into the bleeding site through puncture or intubation under imaging guidance, followed by injection of embolic agents or drugs to achieve hemostasis. Therefore, it is important to develop safe, effective, and convenient hemostatic materials. Hemostatic drugs are currently categorized into 4 main groups: natural polymers, synthetic polymers, inorganic materials, and metal-containing materials [11]. Hemostatic fluid gelatin Surgiflo^® (Ethicon, Somerville, state, USA) is a sterile, absorbable porcine gel fluid gelatin matrix extracted from pig skin [12]. It is suitable for surgical-assisted hemostasis when compression, ligation or other traditional methods are ineffective or impractical for controlling bleeding from capillaries, veins, and small arteries. Surgiflo^® can be directly sprayed onto the bleeding area through a syringe under ultrasound guidance. It has the advantages of traditional gelatin sponge with excellent shape compliance for bleeding wounds and shows a low self-expansion rate after water absorption.

Yu et al [13], under the guidance of CEUS, achieved hemostasis in a rat liver hemorrhage model by percutaneous injection of gelatin/thrombin/calcium (GTC) within a short period of time (without applying pressure). GTC is an absorbable material and can prevent abdominal adhesions. However, the rat model established in that study serves only as a simulation, and the actual efficacy in clinical applications requires further clinical validation. Liu et al [14] performed ultrasound-guided local injection of Lauromacrogol on 15 patients with active bleeding following renal biopsy and achieved successful hemostasis in all cases. No significant differences were observed in postoperative hemoglobin and serum creatinine levels. Lauromacrogol can act directly on the lesion within a short period; it achieves hemostasis by damaging vascular endothelial cells, promoting thrombus formation, stimulating the formation of a protective fibrous tissue layer around the ruptured vessel, enhancing vascular resistance, slowing blood flow, and promoting vascular protection. However, its adverse effects include local vascular rupture, pulmonary artery embolism, and allergic reactions. Hoegger et al [15] included 4 patients undergoing liver biopsy and 12 patients undergoing kidney biopsy in their study and successfully stopped active bleeding in 15 patients by using ultrasound-guided thrombin injections. Thrombin is a serine protease that mediates the conversion of fibrinogen to fibrin. When thrombin is used to manage active bleeding following a kidney biopsy, a large dose of thrombin is injected into the extrarenal space near the bleeding site to stop the hemorrhage, rather than injecting thrombin directly into the blood vessels. If thrombin is inadvertently injected into a blood vessel, it can lead to thrombosis, local necrosis, or even life-threatening complications.

Local injection of fluid gelatin under the guidance of CEUS also has some limitations: (1) fluid gelatin tends to form localized gel blocks at the injection site, which compromises the hemostatic effect; (2) fluid gelatin exhibits stronger echogenicity, which may interfere with ultrasound observation; (3) fluid gelatin degrades slowly, potentially leading to induration at the injection site; and (4) the injection process can cause varying degrees of pain.

The formation of local glue blocks of fluid gelatin at the injection site can affect its hemostatic effect. In this regard, the following issues should be addressed: (1) excessive injection volume: if an excess mount of fluid gelatin is injected, its local concentration may become very high, leading to the formation of a rubber block. Hence, an appropriate injection volume is the key factor to ensure the uniform distribution of fluid gelatin; (2) too fast injection speed: fluid gelatin when injected rapidly may show poor diffusion, resulting in the formation of local aggregates; and (3) characteristics of the injection site: the tissue structure at some injection sites may be more prone to fluid gelatin aggregation, such as areas with abundant blood vessels or dense tissues. To reduce the possibility of the formation of a local glue block, the following precautionary steps are recommended while using fluid gelatin: (1) the injection volume should be controlled to avoid excessive administration; (2) an appropriate injection speed should be maintaining while injecting fluid gelatin to ensure its uniform distribution; and (3) the injection site should be gently massaged after the completion of the injection to enable better dispersion of fluid gelatin.

Fluid gelatin shows strong echo signals in ultrasonography, which can affect ultrasonic observation. This phenomenon could be attributed to the following reasons: (1) material properties: the composition and structure of fluid gelatin may lead to the generation of strong echo signals during ultrasound examination; and (2) state after injection: fluid gelatin may transform into a different physical state after injection, such as gel or solid, which can affect the propagation of ultrasound waves. To reduce the influence of fluid gelatin on ultrasound observation, the following steps should be taken: (1) selection of an appropriate ultrasound probe: the use of ultrasound probes with different frequencies may lead to different observation effects; therefore, selecting the appropriate probe could improve the image quality; (2) adjustment of ultrasound parameters: by adjusting the parameters of ultrasound equipment, such as gain and depth, the image quality can be optimized and the interference of fluid gelatin can be reduced; and (3) combination with other imaging examinations: if fluid gelatin administration greatly affects ultrasound observation, a combination with other imaging examination methods, such as CT or MRI, can be considered to obtain more comprehensive information.

The main mechanism underlying the pain caused by local injection during the treatment of abdominal parenchymal organ trauma-induced hemorrhage may be local adhesive traction pain and local ischemic pain. However, in the present case, the degree of pain was low, and no apparent writhing reaction was triggered. This finding suggests that fluid gelatin is a safe material for treating local hemorrhage.

The complications associated with ultrasound-guided injection of absorbable fluid gelatin primarily involve allergic reactions, procedural trauma, infection, and local tissue responses. The material itself can induce allergic reactions (eg, rash, dyspnea) or local inflammatory responses due to its animal-derived components; however, its absorbable nature reduces the risk of long-term retention. Improper needle placement during the procedure can damage adjacent blood vessels or nerves, potentially leading to bleeding, hematoma, or infection, particularly when aseptic techniques are inadequate. Excessive injection pressure or needle displacement can result in material leakage into unintended areas, causing localized swelling or inflammation.

The most significant risk is embolism – accidental intravascular entry of fluid gelatin may lead to the formation of local thrombi. If these thrombi migrate to the pulmonary circulation, they can cause acute pulmonary embolism and right heart failure, posing a theoretical risk of fatality, although this is extremely rare. Intravascular material can also trigger inflammatory or allergic reactions. Additionally, long-term postoperative complications such as fibrosis or tissue adhesion at the injection site may necessitate anti-scarring interventions. Overall, these risks can be effectively mitigated through preoperative allergy screening, ultrasound-guided precision, strict aseptic protocols, and diligent postoperative monitoring.

CEUS-guided injection of fluid gelatin is not a widely studied treatment method and has limited application, reserved for specific clinical cases and patients who have a higher risk with other more commonly used treatments, such as kidney damage. Further research is needed to more thoroughly explore these issues.

Conclusions

CEUS can be used to accurately identify the location and extent of active bleeding from the inferior epigastric artery before surgery and to closely follow up the postoperative outcomes and monitor the occurrence of delayed complications, thereby allowing patients to receive rapid and effective treatment. CEUS-guided hemostatic material injection provides a safe and effective treatment method and could serve as an effective measure for nonsurgical treatment and postoperative supplementary treatment of active bleeding from the inferior epigastric artery.