# Intractable Delayed Bleeding After Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients With Chronic Disseminated Intravascular Coagulation Caused by Aortic Aneurysm

## TL;DR

A patient with an aortic aneurysm experienced severe bleeding after endoscopic procedures due to an undiagnosed chronic blood clotting disorder.

## Contribution

Highlights chronic DIC caused by aortic aneurysm as a rare but critical cause of intractable delayed bleeding after ESD.

## Key findings

- Chronic DIC caused by an aortic aneurysm was identified as the cause of intractable delayed bleeding after ESD.
- Initial successful hemostasis obscured the underlying clotting disorder, leading to misdiagnosis.
- Gastroenterologists should consider DIC associated with aortic aneurysms during invasive procedures.

## Abstract

Chronic disseminated intravascular coagulation (DIC) is a rare complication of an aortic aneurysm (AA), and it may go unnoticed because patients are often asymptomatic. The condition is sometimes first recognized when trauma or an invasive procedure triggers a sudden and severe difficulty in achieving hemostasis. Here, we report a case of chronic DIC that was diagnosed following intractable delayed bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer. The patient underwent two ESD procedures, one in 2021 and another in 2023, and experienced delayed bleeding after both. In 2021, hemostasis was easily achieved, and complication of his hemodialysis was suspected as the cause of subsequent delayed bleeding. However, when hemostasis proved difficult in 2023, chronic DIC caused by an AA was identified as the primary cause of the intractable bleeding. Although the patient had a mildly reduced platelet count before the initial ESD, the presence of chronic DIC went unnoticed. The successful hemostasis during the first procedure obscured the underlying cause of the bleeding and thrombocytopenia. Gastroenterologists should be aware of enhanced‐fibrinolytic‐type DIC associated with an AA and remain vigilant regarding its high bleeding risk when performing invasive treatments, including endoscopic procedures.