Danis ella stent placement in the management of a lower end esophageal bleeding in a post liver transplant patient: a case report

Background: Danis Ella stent has been used for refrac tory esophageal variceal and post EVL ulcer related bleed. Here we describe its use in an unusual situation. Case Summary: 44 years old male, a chronic alcoholic since last 20 years was diagnosed with decompensated chronic liver disease.He had frequent hospital admissions during last year in view ascites, haemetemesis, encepha lopathy and hepato-renal syndrome respectively. He was evaluated for living donor liver transplantation after 6 months of abstinence.HisMELDat the time of admission was 22 and Child score of 11. After thorough donor work up he underwent LDLT. Right lobe graft without MHV was taken. Graft weight was 665 grams with GRWR of 1.2. Post operative course was complicated by high ascitic fluid drainage, sepsis related acute renal failure. Post oper atively (day 5) patient had malena and fall in hemoglobin (1g%). He required blood transfusions and inotropic sup port in view of hemodyanamic instability. Antimicrobials were escalated empirically. Sepsis screen was sent. Upper GI endoscopy revealed diffuse mucosal oozing from the lower end of esophagus along with small isolated gastric varices. Glue injection was done, however patient contin- ued to bleed despite supportive measures. Repeat UGI scopy was done, which showed continued generalized ooze from lower end of esophagus. Finally endoscopic guided Ella Danis stent was placed with upper end at 25cm from GE junction. The patient was stabilized and moved to the intensive care unit. There was no subsequent evidence of upper GI bleed, however he continued to deteriorate grad- ually due to pulmonary sepsis and eventually succumbed on POD 22. Conclusion: We report the first ever use of Danis Ella stent for diffuse mucosal bleeding from lower esophagus in the setting of post liver transplant. This stent can be used a bridge to stabilize the patient prior to definitive treatment. Nevertheless, randomized trials are needed to confirm the safety and efficacy of this approach.