Bleeding rectal pseudoaneurysm following endoscopic submucosal dissection managed with endoscopic ultrasound-guided absorbable gelatin sponge injection.

Background and Aims: Bleeding secondary to a pseudoaneurysm following endoscopic submucosal dissection (ESD) is exceedingly rare with limited cases reported. Methods: A 74-year-old woman presented with recurrent hematochezia despite conventional endoscopic hemostasis following ESD of a 50-mm rectal polyp. The patient underwent computed tomography angiography that revealed a rectal pseudoaneurysm with active bleeding. She subsequently underwent flexible sigmoidoscopy with EUS. At the site of the adherent clot, a penetrating feeder arterial vessel in the adventitia with a small pseudoaneurysm in the rectal wall (intramural) could be identified on EUS with Doppler. Using a 19-gauge fine-needle aspiration needle primed with saline, we injected 6 mL of absorbable gelatin sponge into the vessel as well as the pseudoaneurysm by EUS guidance, with immediate decrease in Doppler flow after the injection. Results: The patient did well postprocedurally without any recurrent episodes of bleeding, and repeat imaging did not show evidence of a persistent pseudoaneurysm. Conclusions: Arterial pseudoaneurysm is a rare but serious adverse event following ESD. In cases refractory to conventional endoscopic therapy, EUS-guided embolization may offer an effective treatment option.