Repeated hemorrhagic ulcers of the esophagus associated with acquired hemophilia A: A case report

Figure 1 Timeline of the patient’s clinical course. Regarding changes in treatment interventions, for endoscopic hemostasis, radiofrequency ablation was performed a total of 7 times at the previous hospital; however, it was difficult to stop bleeding from the esophageal ulcer. After the patient was transferred to our hospital, endoscopic hemostasis was attempted once, but the effect was insufficient. After the administration of the bypass hemostatic agent, a mixture of factors VIIa and X (Byclot^®) derived from the plasma, the esophageal bleeding stopped. Two weeks later, the patient developed intramuscular bleeding in another area, and Byclot^® was administered again, which stopped the bleeding. To prevent further bleeding, the administration of emicizumab was started, and no rebleeding occurred.

Figure 2 Management of refractory hemorrhage with a novel hemostatic agent: From diagnosis to hemostasis. A and B: Esophageal endoscopic findings at the time of admission. Before treatment, oozing hemorrhage was observed from an ulcer within the hiatal hernia (A); After treatment, clipping was attempted to stop the bleeding, but new bleeding occurred from the clipped area (B); C: Esophageal endoscopic findings of changes in ulcer lesions: A single dose of the hemostatic agent (Byclot^®) resulted in complete hemostasis; D: Computed tomography findings of the intramuscular hematoma: A large intramuscular hematoma was present in the right chest, accompanied by arterial extravasation (indicated by the orange arrow); E: Subcutaneous bleeding finding: Widespread subcutaneous bleeding was observed in the right chest; F: Esophageal endoscopic findings of changes in ulcer lesions: Two weeks after the administration of Byclot^® (around the same time as D and E), the esophageal ulcer remained hemostatic; G: Computed tomography findings of the intramuscular hematoma: Hemostasis was confirmed 5 days after the administration of a mixture of factors VIIa and X (Byclot^®); H: Esophageal endoscopic findings of changes in ulcer lesions: One week after emicizumab administration, the esophageal ulcer showed a marked tendency to heal; I: Subcutaneous bleeding finding: One week after emicizumab administration, the subcutaneous bleeding resolved rapidly.